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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:
    1-800-592-1804 confidential answering-recording device
    1-800-592-1861 or 605-773-3737 for a disease surveillance person during normal business hours
    605-280-4810 after hours to report Category I diseases
    Fax: 605-773-5509
    Outbreak Report           Weekly Influenza Report
    Patient Information Report Type: New  Update Report Date: 4/19/2014
    *Last Name: *First Name: Middle:
    Street Address:    
    Mailing Address:  (if different from Street Address) Zip:
    *City: State: County:
    Home Phone: Other Phone: Work  Cell Pager
    *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? Yes  No Name of Lab: 
    Lab Test Name: Lab Report Date: (mm/dd/yyyy)
    Specimen Source: Date Collected: (mm/dd/yyyy)
    Lab Test Result:
    Facility Ordering Test:
    Was Patient Hospitalized? Yes  No Date Admitted: (mm/dd/yyyy)
    Name of Hospital: Date Discharged: (mm/dd/yyyy)
    Hospital Address: Outcome:  Survived  Expired
    Hospital Phone: Date of Death: (mm/dd/yyyy)
           
    Treatment Information
    Was this person treated? Yes  No  Unknown
    Treatment Provided: Treatment Dosage:
    Treatment Duration: Treatment Date Initiated: (mm/dd/yyyy)
           
    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: 
    Please wait while we process your Disease Report...