Utah County Health Department

151 South University Ave. Ste 2204 Provo, UT Report date:

84601
Phone: (801) 851-7037 Confidential Fax: (801)
343-8151

CHICKEN POX VARICELLA CONFIDENTIAL CASE REPORT

Last Name: First Name: MI:
Address: City: State:
County: Zip: Date of birth: Age:
Phone #1: Phone #2: Phone #3:
Gender: (check one) Race: (check all that apply) Ethnicity: (circle one)
M F White Black/Af. Am American Indian Unknown Hispanic Other
Asian Alaskan Native Native Hawaiian or Pacific Islander Not Hispanic Unknown
CLINICAL INFORMATION
Was patient seen by MD? Y N U Clinician name: Phone:
Was patient hospitalized? Y N U Hospital: Admit date: MR#:
Did patient die? Y N U Date of death: If yes, fill out the Chickenpox Supplemental Death questions.

Date of rash onset: Number of lesions: <50 50-249 250-499 >500 Unk
Diagnosed by: Parent/guardian School Physician/Health Care Worker Self Other:
Has patient had chickenpox previously? Y N U If yes, patient’s age at prior diagnosis:
Is patient pregnant? Y N U
If yes, has Ob/Gyn been notified? Y N U Weeks gestation at onset:

VACCINATION HISTORY
Was patient vaccinated? Y N U Number of doses: Date of last dose:
If no, reason for not vaccinating: Medical contraindication History of previous disease Religious exemption Philosophical objection
Never offered vaccine Outside recommended age range Other:

SCHOOL INFORMATION
Does the patient attend or work in a school or daycare? Y N U If yes, is the patient:
Associated with a daycare? Y N U Name of daycare:
Administrator notified? Y N U

Associated with a school? Y N U Name of school:

Teacher’s name: Grade:

School nurse notified? Y N U Name of nurse:

What grade is patient associated with? Kindergarten Grade school College

REPORTING
Reported by: School nurse/School secretary Hospital/ICP Clinic/doctor’s office Lab General public

Name of the reporter: Phone: Date reported to PH:

LHD Investigator: Phone: Date submitted to UDOH:

LHD Case classification: Confirmed Probable Suspect Pending Out of state Not a case
UDOH Case classification: Confirmed Probable Suspect Pending Out of state Not a case

Fax form to 851-7539; or email to uchlth.lisag@state.ut.us