Infectious Disease Reporting

This form gets securely sent to the Southeast Utah Health Department's Epidemiologist. Information entered here may be used for disease investigation and/or data analysis. All information is kept confidential unless subject to mandatory reporting laws.

1. Patient Name *This question is required.

2. Patient Phone Number *This question is required. This question requires a valid number format.

3. Physician Name *This question is required.

4. Physician Phone Number *This question is required. This question requires a valid number format.

5. Reportable Disease(s): *This question is required.

6. Pertinent information about the patient/disease: *This question is required.