Confidential Infectious Disease Report Form - State Of Alaska, Section Of Epidemiology
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1Confidential Infectious Disease Report Form
State of Alaska, Section of Epidemiology
Health care providers may use this form for to report infectious diseases. Please use the STD/HIV Disease Report Form to report Sexually
Transmitted Diseases and HIV. Forms may be found at
Immediately report any suspected or confirmed public health emergency to 907-269-8000 (during business hours)
or 1-800-478-0084 (afterhours). Diseases classified as public health emergencies are listed in bold on page 6 on the
Disease Reporting Manual ( ).
Patient Information
Last Name _____________________________________ First Name______________________________ MI _______
Date of birth ____/____/______
Sex:
Female
Pregnant:
No
Yes EDC ___/___/____
Unknown
(mm/dd/yyyy)
Male
Transgender
Race:
White
Asian
Ethnicity:
Hispanic
Black
Unknown
Non-Hispanic
Alaska Native/American Indian
Other __________
Unknown
Native Hawaiian/Pacific Islander
Physical Address __________________________________________________
PO Box ___________________
City ______________________________________ State_______
Zip Code ___________________
Phones (home) _______________________ (cell) _____________________
(work) ___________________
Disease Information
Name of Disease_________________________________________________
Was the diagnosis laboratory confirmed?
Yes
No
Specimen Collection Date: ____/____/______
Type of Specimen:
Stool
Serum
CSF
Blood
Other___________________________________
Name of Medical Facility ______________________________________________ Phone ___________________________
Attending Health Care Provider _______________________ Laboratory Name (if known) _____________________________
Reported by: ____________________________________________________ Date Reported: ____/____/_____
Fax reports to (907) 561-4239 – please verify fax has been transmitted.
This form is also available online at
Rev 03/2016
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