Self-Referral Measles Exposure

Self-Referral Measles Exposure

Fill this form if you were exposed to measles. If you have any questions, please contact the Cascade City-County Health Department at 406-791-9242.
Please enter your name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
When were you exposed?*

MonthDayYear
Date
How did you get exposed?*

Friend/Family/Co-worker, etcPublic Exposure (i.e restaurant, shop)UnknownOther
Are you immune to measles?*

Yes, I was born before 1957.Yes, I have record or verified with my healthcare provider that I received the MMR vaccine.Yes, I received the MMR vaccine (but I do not have a record).No, I have not received an MMR vaccine.Unsure/Unknown
Symptoms to watch for:

Fever
Cough
Sneezing
Runny Nose
Red, Watery Eyes
Spots in the Mouth
Rash

If you develop symptoms, please call CCHD at 406-791-9242 and let us know what symptoms you are having. If you need urgent medical care, call the Benefis ER at 406-455-5200 and let them know you are coming in so they can be prepared to see you without exposing other patients.
After filling out this form, would you like a public health staff member to call you?

YesNo
Should be Empty: