IDRS - Infectious Disease Reporting System

Ohio Confidential Reportable Disease
  1. Use this online form to submit reportable infectious diseases to the union County Health Department.
    This form can be completed and submitted electronically to the Union County Health Department.
    It can not be saved for future use.
    (DO NOT use this form to report HIV/AIDS)

    Items with (*) are required fields.

  2. Disease Reported*
    Please enter the disease name
  3. Medical Record Number
  4. ODRS Number

  5. Patient's Last Name*
    Enter the patient's last name.
  6. Patient's First Name*
    Enter the patient's first name.
  7. Middle Name
    (or initial and/or Suffix)
  8. Patient's Address*
    Enter the patient's address.
  9. City*
    Enter the patient's city.
  10. State*
    Invalid Input
  11. ZIP*
    Enter the patient's ZIP code.
  12. County
  13. Home Phone*
    Format patient's phone like this (123-456-7890).
  14. Alternate Number
    Format number like this (123-456-7890).
  15. Birth Date*
    / / Please add a birthdate
  16. Age*
    Enter the patient's age.
  17. Patient Expired
    Invalid Input
  18. Sex*
    Choose a sex.
  19. Pregnant*
    Is the patient pregnant?
  20. Delivery Date
    Invalid Input

  21. Race (Check all that apply)*

    Select a race.
  22. Ethnicity (Check one)*
    Choose an ethnicity.
  23. Was Patient Contacted?
    Invalid Input

  24. Sensitive Occupation? (Check all that apply)

    Invalid Input
  25. Facility Name
    Invalid Input
  26. Facility Address
    Invalid Input

  27. Parent, guardian, or alternate contact name
    Invalid Input
  28. Phone Number
    Format number like this (123-456-7890).
  29. Healthcare Provider Name*
    Healthcare Provider Name
  30. Phone Number
    Format number like this (123-456-7890).
  31. Healthcare Provider Address*
    Healthcare Provider Address
  32. Healthcare Facility Name*
    Healthcare Facility Name
  33. Phone Number
    Format number like this (123-456-7890).
  34. Healthcare Facility Address*
    Healthcare Facility Address
  35. Phone Number
    Format number like this (123-456-7890).

  36. Date of Report*
    Choose a date
  37. Date of Onset*
    Choose a date
  38. Date of Diagnosis*
    Choose a date
  39. Hospital Admission
    Choose a date
  40. Hospital Discharge
    Choose a date
  41. Date of Death
    Choose a date

  42. Status*
    Select one
  43. List Symptoms
    Invalid Input
  44. Date of Result*
    Enter a date

  45. Laboratory Name*
    Laboratory Name
  46. Phone Number*
    Format number like this (123-456-7890).
  47. Laboratory Address*
    Laboratory Address
  48. Date of Specimen Collection*
    Choose a date
  49. Reason for Test*
    Please choose one
  50. Specific Type of Test*
    Invalid Input
    (e.g. smear, culture, ELISA)

  51. Specimen Site/Type*

    Choose at least one
  52. Treatment (required for STD)
    Choose one
  53. Untreated Options

    Invalid Input
  54. Date Treatment Initiated*
    Choose a date
  55. Detail Drugs/Dose/Route*
    Invalid Input

  56. Remarks
    Invalid Input
  57. Enter Your Email to Receive a Copy
    Invalid Input