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Klickitat County Medical Providers Reportable Disease Fax Form Please print clearly or fill out online. Use other reporting forms for HIV, STD and TB Confidential Fax: 773-5991 or 493-4025 N O I T A M R O F N I R E T R O P E R N O I T A M R O F N I T N E I T A P Patient’s Name (last, first and middle initial): Today’s Date (m/d/yr): Date of Birth (m/d/yr): Gender: Male Female Person Reporting: (name and title): : y c n e g A : # t p A : s s e r d d A s ’t n e it a P : e n o h P : e d o C p i Z : y ti C ( ) - Phone Number (home): ( ) - Disease: Phone Number (other): ( ) - Please send: lab report with this fax, and immunization information, if relevant onset date (m/d/yr): Treatment Given (dose, start date, duration): Have you notified the patient/parent/guardian? Yes No Chief Additional Information Please provide to expedite investigation. : n oitc e f n I f o e c r u o S elbis s o P :r e y olp m e r o e r a c dlih c ,lo o h c s f o e m a N Travel Food Drinking water Animal Environment Unknown Person Recreational water Race: Hispanic Ethnicity: Am. Indian/AK Native Na s e Y I P r e h t o /I H e vit o N e tih W r e m A rf A /k c al B n w o n k n U n w o n k n U n ais A Comments: Call 773-4565 or 493-1558 immediately if you confirm or suspect the following: Animal Bites (when human exposure to rabies is suspected) Anthrax Botulism (foodborne, wound, infant) Burkholdieria mallei (Glanders) and pseudomallei (Melioidosis) Cholera Diphtheria Disease of suspected bioterrorism origin Domoic acid poisoning E. coli (Shiga toxin-producing infections including but not limited to E. coli O157:H7) Emerging condition with outbreak potential Haemophilus influenzae (invasive disease, children < age 5) Influenza, novel or untypable strain Measles (rubeola) acute disease only Meningococcal disease (invasive) Monkeypox Outbreaks (suspected foodborne or waterborne) Paralytic shellfish poisoning Plague Poliomyelitis Rabies (confirmed human or animal) Rabies (suspected human exposure) Rubella (including congenital rubella SARS Smallpox Tuberculosis Tularemia Vaccinia transmission Viral hemorrhagic fever Yellow fever