Arboviral Disease Case Report Form
This form can be used to report West Nile, LaCrosse encephalitis (or other California serogrup), Western equine encephalitis, Eastern equine encephalitis, St. Louis encephalitis, Powassan virus, or other arboviral disease to the Minnesota Department of Health.
On this page:
Form
Frequently asked questions
Diseases to report on this form
Returning the completed form
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Form
Download a print version of the form:
- Arboviral Disease Case Report Form (PDF: 40KB/2 pages) Updated 8/2010
Frequently asked questions
- If you have questions regarding this form, please call 651-201-5414.
- When reporting on this form, a Yellow Card is not necessary.
Diseases to report this form
Returning the completed form
- After filling out this form, please return to MDH:
- By mail (please mark the envelope "confidential") to:
Infectious Disease Epidemiology, Prevention and Control
625 North Robert Street
Post Office Box 64975
St. Paul, MN 55164-0975
- By fax to:
651-201-5743
- By mail (please mark the envelope "confidential") to:
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- Download a printable form.
- To receive a copy of this form by mail please call 651-201-5414.
