School Mandatory Disease and Uncommon Event Reporting Form

NOTIFY THE HEALTH DEPARTMENT WITHIN 24 HOURS
This reporting is expressly allowed under HIPAA and required by Michigan Public Act 368 of 1978, 333.5111

Please contact Livingston County Health Department at 517-552-6882 if you have any questions.

1. Reporter Name: *This question is required.

2. Reporter Email: *This question is required. This question requires a valid email address.

3. School/Childcare: *This question is required.Please select the school or childcare location you are completing this report for:

Location Type
Building