Lyme Disease Reporting Form

Contact & Demographic Information

The intention of this survey is to ensure that residents of Washtenaw County diagnosed with Lyme disease are receiving effective treatment, and further, for the health department to better understand the extent of Lyme disease in Washtenaw County.

This form is for individuals who have been diagnosed (clinically and/or with lab testing) with Lyme disease. If you suspect that you may have Lyme disease but have not been evaluated yet, please contact your health care provider.

This survey should take approximately 5 - 10 minutes to complete. This form is secure and HIPAA-compliant. If you have additional questions or concerns, please call the Washtenaw County Health Department at 734-544-6700 or email health@washtenaw.org.

1. Please provide the following information about the person with Lyme disease.

First Name *This question is required.

Last Name *This question is required.

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

calendar

Sex *This question is required.

Please enter an 'other' value for this selection.

Home Address *This question is required.

Street Address
City
State
Zip Code

Primary Phone Number *This question is required.

Phone Number (Other)

Store age from MM/DD/YYY This question requires a valid number format.

2. Please provide parent/guardian contact information if the person with Lyme disease is under 18 years old.

First Name *This question is required.

Last Name *This question is required.

Primary Phone Number *This question is required.

2. Please provide information about the person reporting this case of Lyme disease.

Your relationship to the person with Lyme disease *This question is required.

Please enter an 'other' value for this selection.

First and last name of person reporting *This question is required.

3. Phone number of person reporting *This question is required.

3. Email address of person reporting *This question is required.