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Mandatory Report of Communicable Disease in Michigan

List of reportable conditions in Michigan: Reportable Diseases in Michigan

1. Please enter information below:

Practice/Facility Name
Facility Address (Include City, State, ZIP)
Name of Person Reporting
Phone Number of Person Reporting
Email of Person Reporting
Fax Number of Referring Provider

2. Disease facility is reporting (Please see list of diseases at the beginning of survey):

3. Has/Will patient be notified of diagnosis?

4. Estimated onset date of the disease, infection, or condition:

5. Please enter patient information:

	First Name
	Last Name
	Date of Birth (MM/DD/YYYY)
	If minor, name of parent/guardian:
	Address (include City, State, ZIP)
	Phone Number
	Email

6. Patient Race/Ethnicity:

Please enter an 'other' value for this selection.

7. Patient Gender:

Please enter an 'other' value for this selection.

8. Was patient hospitalized?

9. Name of hospital:

9. Are you reporting an STI?

10. STI Treatment:

Date of Treatment (MM/DD/YYYY)
Specify Drug/Dose
Duration of Treatment
Is Patient Pregnant (Yes/No)
Was Partner Treated? (EPT)

10. Any other information considered by the healthcare provider to be related to the health of the public (e.g., other ill family members/contacts, food handler, group living situation, day care attendee/employee):