Measles Exposure Monitoring Survey
Help us monitor and prevent the spread of measles by providing information about your recent exposure and symptoms.
Full Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Possible Measles Exposure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Possible Exposure (e.g., school, workplace, public place)
*
Are you currently experiencing any of the following symptoms? (Select all that apply)
*
Fever
Rash
Cough
Runny nose
Red or watery eyes
None of the above
Other
Have you received the measles (MMR) vaccine?
*
Yes, fully vaccinated (2 doses)
Yes, partially vaccinated (1 dose)
No
Not sure
Have you traveled outside your local area in the past 21 days?
*
Yes
No
If yes, please list the places you have traveled to in the past 21 days.
Submit Survey
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