Social Media linksWEBSITE OF THE STATE OF SOUTH DAKOTA DEPARTMENT OF HEALTH
Kim Malsam-Rysdon, Secretary of Health
South Dakota Confidential Disease Report
South Dakota Department of Health
Office of Disease Prevention
SDCL 34-22-12 and ARSD 44:20     Reportable Disease List
Instructions:
  • Please fill out the form as completely as possible before submission.
  • Use the Tab key to move to the next field.
  • Only press the Enter key when you are ready to submit the form.
  • Note: Fields with an asterisk(*) are required.
 Other disease reporting options:
Phone:
1-800-592-1861 or 605-773-3737 for a disease surveillance person during normal business hours
Fax: 605-773-5509
Outbreak Report           Weekly Influenza Report
Patient Information Report Type: Report Date:  12/10/2019
*Last Name: *First Name: Middle:
Street Address:    
Mailing Address:  (if different from Street) Zip:  
*City: State: County:
Home Phone: Other Phone:
*Race: *Ethnicity:
Occupation: *Date of Birth: (mm/dd/yyyy) *Gender:
Email Address:      
Disease Information
*Disease or Condition: 
Date of Onset: (mm/dd/yyyy)    
*Diagnosis confirmed by Lab Test? Name of Lab: 
Lab Test Name: Date Collected: (mm/dd/yyyy)
Specimen Source: Lab Report Date: (mm/dd/yyyy)
Lab Test Result:
Facility Ordering Test:
*Was Patient Hospitalized? Date Admitted: (mm/dd/yyyy)
Name of Hospital: Date Discharged: (mm/dd/yyyy)
Hospital Address:
Hospital Phone:
Outcome: Date of Death: (mm/dd/yyyy)
Specimen Ship Date: (mm/dd/yyyy) Specimen Estimated Arrival: (mm/dd/yyyy)
Shipping Comments
Treatment Information
Was this person treated?
Treatment Provided: Treatment Dosage:
Treatment Duration: Treatment Date Initiated: (mm/dd/yyyy)
       
Date Collected: (mm/dd/yyyy) Specimen Source:
Lab Test Name: Lab Test Result:
Name of Lab:  Lab Report Date: (mm/dd/yyyy)
Facility Ordering Test:
Clinical & Treatment Information
Was this person symptomatic? Date of Onset: (mm/dd/yyyy)
  Duration of Symptoms: (days)
Estimate Date of Last Sexual Exposure: (mm/dd/yyyy)
Was this person treated?
Treatment Provided: Treatment Date Initiated: (mm/dd/yyyy)
Other Treatment:    
Pregnant? Weeks Pregnant:
Tested for HIV?   Date: (mm/dd/yyyy) HIV Test Results:
Attending Health Care Provider
First Name: Last Name: Suffix:
Phone: Ext:    
Comments:         
           
Person Reporting
*First Name: *Last Name: Suffix:
*Phone: Ext: Email:  
*Facility Name:
  To add or change your facility name please spell out the name(no abbreviations) in the text box below before submitting this form.
  New Facility Name: 

Report Partners of this Patient
No Partners added