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Reportable Disease Case Report Form

This form should be used to provide Health Department notification of reportable conditions. Please provide as complete information as possible. Do not use this form to report COVID-19 or routine Lyme disease cases, or conditions that are immediately notifiable (for example, measles, hepatitis A,  tuberculosis disease, and meningococcal disease). Immediately notifiable conditions should be reported by calling 802-863-7240
This question requires a valid date format of MM/DD/YYYY.
Please enter the name of the person completing the form.
Is the reporter the same as the reporting facility's provider?Examples of reporting facility providers include: school nurse, director of nursing, medical director, infection preventionist, etc.