WATERBORNE ILLNESS REPORT FORM
Information about you
Are you reporting for yourself or someone else?
Myself
Someone else (if someone else, please complete this form using the information of the person you are reporting for)
Name
First Name
Last Name
Age (years)
years
Sex
Male
Female
Best contact phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Please re-enter best contact phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
Please re-enter email address
Information about possible waterborne exposure
Date of Exposure
-
Month
-
Day
Year
Date Picker Icon
Time of Exposure
Hour Minutes
AM
PM
AM/PM Option
Exposure location
Weather at time of exposure
Activity and amount of time in water
Surf condition
Please describe any symptoms that might be related to the possible exposure as well as the date the symptom started
Was there anything unusual about the water (color, odor, foam, dead organisms)?
Please describe any other recent exposures to other water bodies
Was there other previous exposure to illness around this time? (such as friends or family)
Did you seek medical attention?
Yes
No
Not yet, but it is scheduled
Unsure
Submit
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