Follow the steps to fill out the KS KDHE Reportable Disease Form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering today’s date in the format MM/DD/YYYY.
3. Fill in the patient’s name, including last, first, and middle names.
4. Provide the home/cell phone number and work phone number for the patient.
5. Enter the residential address, including the city and zip code.
6. Select the ethnicity and race of the patient, checking all that apply.
7. Indicate the patient’s sex by selecting M for Male or F for Female.
8. If known, provide the patient’s date of birth. If the date of birth is unknown, enter the patient’s age.
9. Input the disease name being reported.
10. Indicate whether the patient or guardian has been notified of the disease by selecting Yes or No.
11. List the onset date of symptoms in the format MM/DD/YYYY.
12. List the three most prominent symptoms experienced by the patient.
13. Indicate if there is an outbreak association by selecting Yes or No.
14. Specify the institutional residence if applicable (i.e., nursing home, correctional facility) or select None.
15. Note whether the patient has died by selecting Yes or No.
16. Provide the physician’s name and phone number responsible for the patient's care.
17. Fill in the laboratory information, including specimen collection date, date reported, name of the test performed, name of the laboratory, results of the test, and whether laboratory results are attached.
18. Provide treatment information, including date of treatment, treatment status, type, and dosage.
19. Enter the name and phone number of the person reporting the disease.
20. Add any additional comments if necessary.
21. After filling out all required fields, users can save the changes, download, print, or share the completed form.

Complete your report by filling out the KS KDHE Reportable Disease Form online.