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?*

Healthcare facilityLocal or tribal public healthOther
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?*

Yes- I'm only uploading documentsNo- I need to enter patient and specimen information

Patient Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Is the patient a Montana resident?*

YesNoOther
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)?

YesNoUnknown
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 Travel & Visitors
Within Montana Travel
Did the patient travel within Montana in the last month?*

YesNoUnknown
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
Date
Date arrived back in home town

MonthDayYear
Date
Out of State Travel
Does the patient have out of state travel in the last month?*

YesNoUnknown
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
Date
Date returned to Montana

MonthDayYear
Date
Visitors
Has the patient had any visitors in the last month?*

YesNoUnknown
Where were the visitors from?
Visit Date, Start

MonthDayYear
Date
Visit Date, End

MonthDayYear
Date
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