Union County Health Department

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







    Select a race.
  24. Ethnicity (Check one)*
    Choose an ethnicity.
  25. Was Patient Contacted?
    Invalid Input
  27. Sensitive Occupation? (Check all that apply)





    Invalid Input
  28. Facility Name
    Invalid Input
  29. Facility Address
    Invalid Input
  31. Parent, guardian, or alternate contact name
    Invalid Input
  32. Phone Number
    Format number like this (123-456-7890).
  33. Healthcare Provider Name*
    Healthcare Provider Name
  34. Phone Number
    Format number like this (123-456-7890).
  35. Healthcare Provider Address*
    Healthcare Provider Address
  36. Healthcare Facility Name*
    Healthcare Facility Name
  37. Phone Number
    Format number like this (123-456-7890).
  38. Healthcare Facility Address*
    Healthcare Facility Address
  39. Submitted By (contact name, facility)*
    (contact name, facility)
  40. Phone Number
    Format number like this (123-456-7890).
  42. Date of Report*
    Choose a date
  43. Date of Onset*
    Choose a date
  44. Date of Diagnosis*
    Choose a date
  45. Hospital Admission
    Choose a date
  46. Hospital Discharge
    Choose a date
  47. Date of Death
    Choose a date
  49. Status*
    Select one
  50. List Symptoms
    Invalid Input
  51. Date of Result*
    Enter a date
  53. Laboratory Name*
    Laboratory Name
  54. Phone Number*
    Format number like this (123-456-7890).
  55. Laboratory Address*
    Laboratory Address
  56. Date of Specimen Collection*
    Choose a date
  57. Reason for Test*
    Please choose one
  58. Specific Type of Test*
    Invalid Input
    (e.g. smear, culture, ELISA)
  60. Specimen Site/Type*








    Choose at least one
  61. Treatment (required for STD)
    Choose one
  62. Untreated Options




    Invalid Input
  63. Date Treatment Initiated*
    Choose a date
  64. Detail Drugs/Dose/Route*
    Invalid Input
  66. Remarks
    Invalid Input
  67. Enter Your Email to Receive a Copy
    Invalid Input

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