Surveillance report form printable 2026

1. Click ‘Get Form’ to open the surveillance report form in the editor.
2. Begin by filling out the Demographic Data section. Enter the Reporting State, the first three letters of the patient’s last name, and their date of birth. Indicate the patient's sex and whether they work as a food handler.
3. In the Clinical Data section, answer questions regarding hospitalization and symptoms. Specify if the patient was hospitalized, provide dates of symptom onset, and indicate if they experienced fever or abdominal pain.
4. Proceed to Laboratory Data. Check all applicable sites of isolation and indicate if antibiotic sensitivity testing was performed. Provide details on any resistance found.
5. Complete the Epidemiologic Data section by answering questions about outbreaks, vaccinations, travel history, and case tracing. Fill in any comments and provide your contact information at the end.

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