Infectious Disease Exposure Communication Form
Use this form to notify and document a possible infectious disease exposure. Please provide accurate and complete information.
Reporter Full Name
*
First Name
Last Name
Reporter Email Address
*
example@example.com
Reporter Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date and Time of Exposure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Exposure
*
Describe the Exposure Incident
*
Name or Identifier of Affected Person
Are there any symptoms present?
*
Yes
No
Unknown
Potential Source of Exposure
Actions Already Taken
*
Submit Report
Should be Empty: