Reportable Disease Case Report Form

This form should be used to provide Health Department notification of reportable conditions. Please provide as complete information as possible. Do not use this form to report routine Lyme disease cases, or conditions that are immediately notifiable (for example, measles, hepatitis A, tuberculosis disease, and meningococcal disease). Immediately notifiable conditions should be reported by calling 802-863-7240

Condition Diagnosis

Was a lab-based test conducted?

Date of specimen collection? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Date of Report *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Reported By: *This question is required. Please enter the name of the person completing the form.

Reporter Phone Number (use xxx-xxx-xxxx format): *This question is required.

Reporting Facility Name: *This question is required.

Is the reporter the same as the reporting facility's provider?Examples of reporting facility providers include: school nurse, director of nursing, medical director, infection preventionist, etc.

Reporting Facility Provider Name:

Reporting Facility Provider Phone Number: