Harmful Algal Bloom (Hab) Human Illness Report Form - Illinois Download Pdf
Download pdf

Harmful Algal Bloom (Hab) Human Illness Report Form - Illinois

This fillable "Harmful Algal Bloom (Hab) Human Illness Report Form" is a document issued by the Illinois Department of Public Health specifically for Illinois residents.

Download the PDF by clicking the link below and complete it directly in your browser or through the Adobe Desktop application.

ADVERTISEMENT
Show Pagination
HARMFUL ALGAL BLOOM (HAB)
HUMAN ILLNESS REPORT
Illinois Department of Public Health
Communicable Disease Control Section
Phone: 217-782-2016 Fax: 217-524-0962
Reporting Entity:
General Public
Health Care Provider
Poison Control Center
Local Agency
State Agency
Other_______________________
Contact Name_________________________________ Phone Number____________________home/work/cell
Identifying information for case:
Name_______________________________________ Phone Number_____________________home/work/cell
Address______________________________________________ County_______________________________
Demographic information for case:
Height: _____’_____”
Weight: ________lbs
Date of Birth ______/______/__________
Sex:
Ethnicity:
Male
Female
Hispanic
Non-Hispanic
Race:
American Indian
Asian
Black
White
Unknown
Other___________
Suspected source of exposure:
Public water body (name and location)________________________________________________________
Home/private water body (name and location)__________________________________________________
Food (type)______________________________________________________________________________
Drinking water (source/location)__________________
Other (describe)__________________________
If exposure source was a water body:
Visible algae present:
Yes
No
Unknown
Odor:
Yes
No
Unknown
Describe water body color and appearance_____________________________________________________
Sick or dead animals present (type, number):
Yes
No
Unknown _____________________________________________________________
Activities during exposure to water body:
Swimming
Wading
Boating
Fishing
Tubing/skiing
Other______________________
HARMFUL ALGAL BLOOM (HAB)
HUMAN ILLNESS REPORT
Illinois Department of Public Health
Communicable Disease Control Section
Phone: 217-782-2016 Fax: 217-524-0962
Reporting Entity:
General Public
Health Care Provider
Poison Control Center
Local Agency
State Agency
Other_______________________
Contact Name_________________________________ Phone Number____________________home/work/cell
Identifying information for case:
Name_______________________________________ Phone Number_____________________home/work/cell
Address______________________________________________ County_______________________________
Demographic information for case:
Height: _____’_____”
Weight: ________lbs
Date of Birth ______/______/__________
Sex:
Ethnicity:
Male
Female
Hispanic
Non-Hispanic
Race:
American Indian
Asian
Black
White
Unknown
Other___________
Suspected source of exposure:
Public water body (name and location)________________________________________________________
Home/private water body (name and location)__________________________________________________
Food (type)______________________________________________________________________________
Drinking water (source/location)__________________
Other (describe)__________________________
If exposure source was a water body:
Visible algae present:
Yes
No
Unknown
Odor:
Yes
No
Unknown
Describe water body color and appearance_____________________________________________________
Sick or dead animals present (type, number):
Yes
No
Unknown _____________________________________________________________
Activities during exposure to water body:
Swimming
Wading
Boating
Fishing
Tubing/skiing
Other______________________
Exposure details
Suspected routes(s) of exposure:
Inhalation
Drinking/Swallowing
Skin contact
Other__________________________________
Date(s) of exposure:
______/______/__________
______/______/__________
______/______/__________
Total duration of exposure: __________________minutes/hrs/days
Symptoms:
Did case seek medical attention?
Yes
No
Onset Date of Symptoms ______/______/__________
Duration of Symptoms ___________ days
General:
Fever
Headache
Nasal Congestion
Fatigue
Eye redness/irritation
Sore throat
Respiratory:
Cough
Wheezing
Shortness of breath
Gastrointestinal:
Nausea
Vomiting
Diarrhea
Muscular/skeletal:
Muscle pain
Joint pain
Difficulty walking
Neurologic:
Numbness
Blurred vision
Tingling/burning
Confusion
Paralysis
Seizures
Coma
Dermal:
Rash
Blisters
Itching
Other symptoms (please describe)____________________________________________________
Are you aware of other people that were exposed and became ill?
Yes
No
If yes:
Name and contact information of exposed person(s)_________________________________________
Exposure/illness description_____________________________________________________________
Please mail or fax completed form to the Illinois Department of Public Health Communicable Disease
Control Section. Mailing address: 525 W Jefferson St., Springfield IL 62761. Fax: 217-524-0962

Download Harmful Algal Bloom (Hab) Human Illness Report Form - Illinois

601 times
Rate
4.3(4.3 / 5) 36 votes
ADVERTISEMENT
Illinois Department of Public Health Illinois Legal Forms
Download
Page of 2