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

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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
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