Foodborne Disease Reporting Form
This form can be used to report amebiasis, campylobacteriosis, cryptosporidiosis, cyclospora, E. coli infection, giardiasis, listeriosis, salmonellosis, shigellosis, trichinosis, vibrio, or yersiniosis 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:
- Foodborne Disease Reporting Form (PDF: 39KB/2 pages) Updated 6/2010
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
- Reporting Amebiasis (Entamoeba histolytica/dispar)
- Reporting Campylobacteriosis (Campylobacter spp.)
- Reporting Cryptosporidiosis (Cryptosporidium spp.)
- Reporting Cyclosporiasis (Cyclospora spp.)
- Reporting Enteric Escherichia Coli Infection
- Reporting Giardiasis (Giardia lamblia)
- Reporting Listeriosis (Listeria monocytogenes)
- Reporting Salmonellosis, including typhoid (Salmonella spp.)
- Reporting Shigellosis (Shigella spp.)
- Reporting Trichinosis (Trichinella spiralis)
- Reporting Vibrio spp.
- Reporting Yersiniosis (Yersinia species)
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:
Order more forms
- Download a printable form.
- To receive a copy of this form by mail please call 651-201-5414.
