We've detected that Javascript is not enabled. It is required for an optimal survey taking experience.
Please check your browser's settings and make sure Javascript is turned on. Learn how to enable Javascript.

Skip survey header

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 517-546-9850 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 where ill student attends: *This question is required.

If selected "Other," please list school name *This question is required.

If selected "Other," please specify *This question is required.

5. Classroom Teacher's Name: *This question is required.

6. When did the student's symptoms begin? This question requires a valid date format of MM/DD/YYYY.

calendar

7. Last date that student was in school: *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

8. Choose Reportable Condition/Illness: *This question is required.For a complete list of conditions, click here.

Please enter an 'other' value for this selection.

9. Ill Student's Full Name: *This question is required.

10. Parent/Guardian's Name: *This question is required.

11. Parent/Guardian's Phone Number: (Enter numbers only) *This question is required. This question requires a valid number format.

12. Ill Student's Date of Birth: *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

13. Student's Sex: *This question is required.

14. Student's Race:

15. Student's Full Address - Please include street number, name, city, and ZIP code

Address Line 1
Address Line 2
City
ZIP Code

16. Please provide any comments that will help us better understand the reportable condition: