PLEASE REPORT THESE CONDITIONS AS SOON AS POSSIBLE

NOTIFIABLE DISEASES
ACQD. IMM. DEF. SYND. (AIDS) (S) 
AMOEBIASIS
ANTHRAX (T) 
ARBOVIRUSES 
BABESIOSIS 
BOTULISM (T) 
BRUCELLOSIS
CAMPYLOBACTERIOSIS 
CHANCROID (S) 
CHLAMYDIA (S) 
CHOLERA 
COCCODIOIDOMYCOSIS
CREUTZFELDT-JAKOB DISEASE (T) 
CRYPTOSPORIDIOSIS 
CYCLOSPORIASIS
CYTOMEGALOVIRUS (NEONATAL ONLY) 
DENGUE FEVER (T)
DIPHTHERIA (T)
ENTERHEMORRHAGIC E. COLI INCLUDING BUT NOT LIMITED TO E.COLI 0157:H7 (T) 
EHRLICHIOSIS
ENCEPHALITIS
FOODBORNE DISEASE OUTBREAKS (T) 
GIARDIASIS
GLANDERS  (T) 
GONORRHEA (S) 
GRANULOMA INGUINALE (S) 
GUILLAIN-BARRE
HANSEN’S DISEASE (LEPROSY) 
HANTAVIRUS INFECTION (T) 
HAEMOPHILUS INFLUENZAE, INVASIVE
HEMOLYTIC UREMIC SYNDROME (HUS) (T)
HEPATITIS A (T)
HEPATITIS B (S)
HEPATITIS C & UNSPECIFIED 
HERPES (CONGENITAL) (S) 
HERPES (GENITAL) (N) 
HISTOPLASMOSIS
HUMAN IMMUNODEFICIENCY VIRUS (HIV) 
HUMAN PAPILLOMAVIRUS (GENITAL WARTS) (S) 
INFLUENZA
INFLUENZA ASSOC. INFANT MORTALITY (T) 
KAWASAKI SYNDROME
LEAD POISONING 
LEGIONELLOSIS 
LEPTOSPIROSIS 
LISTERIOSIS 
LYME DISEASE
LYMPHOGRANULOMA VENEREUM (S) 
MALARIA
MEASLES (T) 
MELIODOSIS
MENINGITIS (ALL TYPES OTHER THAN MENINGOCOCCAL)
MENINGOCOCCAL INFECTIONS (ALL TYPES ) (T) 
MONKEY POX 
MUMPS (T) 
NOROVIRUS
NOSOCOMIAL DISEASE OUTBREAK (T) 
PELVIC INFLAMMATORY DISEASE (N. GONORRHEA, C. TRACHOMATIS OR UNSPECIFIED) (S)
PERTUSSIS (T) 
PLAGUE (T)
POLIOMYELITIS (T)
PSITTACOSIS 
Q FEVER
RABIES (MAN, ANIMAL) (T) 
REYE SYNDROME 
RHEUMATIC FEVER
RICIN TOXIN 
RICKETTSIAL DISEASE
ROCKY MOUNTAIN SPOTTED FEVER 
RUBELLA (T)
RUBELLA (CONGENITAL) (T) 
SALMONELLOSIS
SEVERE ACUTE RESPIRATORY SYNDROME (SARS) 
SHIGATOXIN PRODUCTION 
SHIGELLOSIS
SILICOSIS 
SMALLPOX
STAPHYLOCOCCAL ENTEROTOXIN 
STREPTOCOCCAL DISEASE (INVASIVE GROUP A OR B) 
STREPTOCOCCAL TOXIC SHOCK SYNDROME (STSS) 
SYPHILIS (S)
SYPHILIS (CONGENITAL) (T) (S) 
TETANUS
TOXIC SHOCK SYNDROME 
TOXOPLASMOSIS 
TRICHINOSIS 
TUBERCULOSIS (T) 
TULAREMIA (T)
TYPHOID FEVER (T)
TYPHUS FEVER (ENDEMIC FLEA BORNE, LOUSE BORNE, TICK BORNE)
VACCINE ADVERSE REACTIONS
VARICELLA (CHICKENPOX) 
VIBRIO, NON-CHOLERA
VIRAL HEMORRHAGIC FEVERS (T) 
WATERBORNE DISEASE OUTBREAKS (T) 
YELLOW FEVER (T)
YERSINIOSIS

(T) report by rapid means (telephone, fax or other electronic means)
(N) report in number only when so requested
For all diseases not marked by (T) or (N):
(S) sexually transmitted disease, report required within 24 hours
Others - report required within 48 hours

DRUG RESISTANT ORGANISMS REQUIRED TO BE REPORTED
ENTEROCOCCUS SPECIES, VANCOMYCIN RESISTANT 
ESBL RESISTANCE (EXTENDED-SPECTRUM ß-LACTAMASES) 
STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT (MRSA) 
STAPHYLOCOCCUS AUREUS, VANCOMYCIN INTERMEDIATE OR RESISTANT (VISA, VRSA) 
STREPTOCOCCUS PNEUMONIAE, INVASIVE (SENSITIVE AND RESISTANT) 

Effective 2/10/2006


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				DELAWARE DIVISION OF PUBLIC HEALTH
					Disease Report Form


Race ________________

Sex _________________

Name _______________________________________________________________________________________

Phone ____________________________________________________ Birthdate _______________________ 

Address  ______________________________________________________________ Zip code ___________ 

School or Type of Employment _______________________________________________________________ 

Disease or Condition _______________________________________________________________________ 

Date of Onset ______________________________________________________________________________ 

Laboratory Data ____________________________________________________________________________ 

Hospital ___________________________________________________________________________________ 

Remarks ____________________________________________________________________________________ 

Physician’s Name ____________________________________________________ Phone ________________
                                   (please print)
Address ____________________________________________________________________________________ 

Date ___________________________________     _______________________________________________
                                                   Signature of Person Reporting

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MAIL TO:	DIVISION OF PUBLIC HEALTH
		EPIDEMIOLOGY
		417 FEDERAL STREET
		DOVER, DE  19901