Enteric Disease Reporting Form

Foodborne Case Reporting Form - Minnesota Dept. of HealthFoodhandler: Yes No Unknown If yes, restaurant name: Childcare attendee/worker: Yes No Unknown If yes, childcare center name:
Antibiotics prescribed: Yes No Unknown If yes, antibiotic name: Antibiotic treatment date:
Did the patient travel outside the United States one week prior to illness onset: Yes No Unknown
Did the patient develop hemolytic uremic syndrome (HUS): Yes No Unknown (If yes, please complete HUS form)
› Hospital/Clinic Information
Lab: Lab phone:
Reporter Provider Lab Other:
Lab result date:
Hospitalized: Yes No Unknown If yes, admit date: Discharge date:
Hospital name:
Patient status at time of reporting: Alive Dead Date of death:
Pregnant (if applicable): Yes No If yes, due date:
› Patient Demographic Information
Date of birth: Patient age: Medical record #:
Preferred Language: English Other:
Gender: Male Female Transgender Unknown
Address: County:
Phone: Alternate phone:
Occupation: Parent/guardian name:
Race (check all that apply): American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander White
Black/African American Unknown Other:
10/2017
Minnesota Dept. of Health 625 N Robert St. St. Paul, MN 55164 Phone: 651-201-5414 | Fax: 1-800-233-1817
Enteric Disease Reporting Form This form can be used to report Amebiasis, Campylobacter spp., Cryptosporidium spp., Cyclospora spp., E. coli infection,
Giardia, Listeria spp., Salmonella spp., Shigella spp., Trichinosis, Vibrio spp., Yersinia spp.
Check Box foodhandler yes: Off
Check Box foodhandler no: Off
Check Box foodhandler unknown: Off
Text Field if yes restaurant name:
Check Box childcare attendee/worker yes: Off
Check Box childcare attendee/worker no: Off
Check Box childcare attendee/worker unknown: Off
Text Field if yes childcare name:
Check Box antibiotics prescribed yes: Off
Check Box antibiotics prescribed no: Off
Check Box antibiotics prescribed unknown: Off
Text Field if yes antibiotic name:
Text Field if yes antibiotic treatment date month:
Text Field if yes antibiotic treatment date day:
Text Field if yes antibiotic treatment date year:
Check Box patient travel outside US one week prior to illness yes: Off
Check Box patient travel outside US one week prior to illness no: Off
Check Box patient travel outside US one week prior to illness unknown: Off
Check Box patient develop hemolytic uremic syndrome yes: Off
Check Box patient develop hemolytic uremic syndrome no: Off
Check Box patient develop hemolytic uremic syndrome unknown: Off
Text Field reporter name:
Text Field reporting institution:
Text Field ordering provider:
Text Field provider phone:
Text Field specimen source:
Text Field if yes admit date month:
Text Field if yes admit date day:
Text Field if yes admit date year:
Text Field discharge date month:
Text Field discharge date day:
Text Field discharge date year:
Text Field hospital name:
Text Field pregnant due date month:
Text Field pregnant due date day:
Text Field pregnant due date year:
Text Field last name:
Text Field first name:
Text Field middle name:
Text Field patient age:
Text Field medical record:
Check Box country of birth united states: Off
Check Box country of birth other: Off
Text Field country of birth other :
Check Box country of birth unknown: Off
Check Box gender male: Off
Check Box gender female: Off
Check Box gender transgender: Off
Check Box gender unknown: Off
Text Field address:
Text Field county:
Text Field city:
Text Field state:
Text Field zip:
Check Box homeless: Off
Check Box unknown: Off
Check Box race asian: Off
Check Box race native hawaiian/pacific islander: Off
Check Box race white: Off
Check Box race black/african american: Off
Check Box race unknown: Off
Check Box race other: Off
Text Field race other:
Text Field disease name:
Text Field onset date: