Suspect Measles Report Form

Suspect Measles Report Form

Montana DPHHS
Reporter Information
Reporter Name

First NameLast Name
Reporter's Job Title or Role
e.g., registered nurse, congregate-living coordinator, health director
Reporter Phone
Please enter a valid phone number.Format: (000) 000-0000.
Reporter's Email
Please enter a valid email.
Are you reporting for a healthcare facility or as a local or tribal public health agency?

Other
Thank you for reporting! Make sure to also contact your local health office if you have not already done so. (Local and Tribal Health Jurisdiction Contact Information)
Reporting Facility Name & Location
e.g. Lewis & Clark Hospital in Helena, Montana
Are you using this JotForm ONLY for uploading documents?

Patient Information
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Is the patient a Montana resident?
Montana Jurisdiction of Residence
County and/or tribal jurisdiction of residence
Patient's Home State or Country Address
e.g. 1234 Disney World Lane, Mystic City, Florida
Was the patient at school or daycare during their infectious period (4 days prior to rash onset and 4 days after rash onset)?
What school or daycare did this patient attend during their infectious period?
What day(s) and time(s) was the patient at school or daycare during their infectious period?

Patient Symptoms
Symptom History

Other
Rash Onset Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearif unknown, put 01/01/1900
Rash Type and Progression
e.g. flat rash started at palms and spread to trunk
Fever Onset Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Highest Temperature Recorded
Additional Symptom Details

Patient Travel & Visitors
Within Montana Travel
Did the patient travel within Montana in the last month?
Where has the patient traveled in Montana?
Please be as specific as possible, e.g. The patient visited Bozeman for a college visit at Montana State University.
Date departed from home town

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date arrived back in home town

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Out of State Travel
Does the patient have out of state travel in the last month?
Where has the patient traveled?
Please be as specific as possible, e.g. The patient visited multiple theme parks in Orlando, Florida
Date departed from Montana

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date returned to Montana

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Visitors
Has the patient had any visitors in the last month?
Where were the visitors from?
Visit Date, Start

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Visit Date, End

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Were any visitors ill during their stay, or shortly after?
Additional Information
Use this to include additional travel locations/dates, further details about the nature of their potential exposures, etc.

Optional: Upload Files

e.g., provider's notes, immunization records, etc.
Cancelof
Additional Comments/Information
The MTPHL courier schedule can be found here.

Testing for measles illness is being performed at MTPHL Monday - Friday (excluding holidays). PCR specimens must arrive at MTPHL in Helena by 9am Monday - Friday for same-day testing.

Results from measles testing completed at MTPHL will be available in both the MTPHL portal and MIDIS. CDEpi staff will contact local or tribal public health in the event that the test result is positive. Negatives test results will appear in MIDIS and the MTPHL portal.
Should be Empty:

Reporter Information