Hantavirus Exposure Intake Form
Please use this Hantavirus Exposure Intake Form to document details about a potential hantavirus exposure event. Complete all sections to help us understand the incident.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
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 (address, facility, or area description)
*
Type of Exposure
*
Direct contact with rodents
Direct contact with rodent droppings
Cleaning rodent-infested area
Working in an area with rodents
Other
Did you have possible contact with rodents or rodent droppings?
*
Yes
No
Unsure
Are you experiencing any symptoms?
*
Fever
Muscle aches
Shortness of breath
Cough
Headache
Nausea or vomiting
No symptoms
Other
Are you currently receiving any medical attention for this exposure?
*
Yes, hospitalized
Yes, outpatient care
No
Not yet, planning to seek care
Additional notes or details about the exposure event
Submit
Should be Empty: