Public Health Incident Report Form
Report a public health incident to help ensure prompt response and resolution.
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Incident Location (address or description)
*
Type of Incident
*
Please Select
Infectious Disease Exposure
Foodborne Illness
Environmental Hazard
Injury/Accident
Chemical/Biological Exposure
Other
Brief Description of the Incident
*
Number of Individuals Affected
*
Details of Affected Individuals (age group, symptoms, etc.)
Were any immediate actions taken?
*
Yes
No
If yes, please describe the actions taken
Have authorities or public health officials been notified?
*
Yes
No
Please upload any supporting files or photos (optional)
Upload a File
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Choose a file
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Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Report
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