Tickborne Disease Case Report Form
This form can be used to report Lyme disease, Babesiosis, Human anaplasmosis, Human ehrlichiosis, Rocky Mountain spotted fever, and other tickborne 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:
- Tickborne Disease Case Report Form (PDF: 40KB/2 pages) Updated 7/2012
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 Lyme Disease (Borrelia burgdorferi)
- Reporting Babesiosis (Babesia spp.)
- Reporting Anaplasmosis (Anaplasma phagocytophilum)
- Reporting Ehrlichiosis (Ehrlichia spp.)
- Reporting Rocky Mountain Spotted Fever (Rickettsia spp.)
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.
