Forms, Referrals & Ordering

Vaccines and immunization

0-18 Report of Immunization form (PDF, 1 page, 102 KB)
Report of Adverse Event Following Immunization (AEFI) (PDF, 1 page, 180 KB)
Medical Exemption Form
School Based Vaccine Request Form (Hep B, Menactra, and HPV) (PDF, 1 page, 755 KB)
Vaccine Order Form (PDF, 1 page, 243 KB)
Vaccine Return Form (PDF, 1 page, 439 KB)
Vaccine Temperature Log Book (PDF, 26 pages, 3 MB)

Infectious Disease Risk Assessment Form for Emergency Services Workers (PDF, 6 pages, 657 KB)
Confidential Hepatitis B Questionnaire (PDF, 2 pages, 1.7 MB)
Follow-up Reporting Form for Infants Born to Hepatitis B+ Mothers (PDF, 1 page, 193 KB)
Hepatitis PCR Requisition: Hepatitis C RNA and/or Hepatitis B DNA Viral Load (PDF, 3 pages, 187 KB)
Confidential Hepatitis C Questionnaire (PDF, 2 pages, 196 KB)
Rabies Exposure Report (PDF, 1 page, 168 KB)
Rabies Vaccine & Immune Globulin: Patient Vaccination Schedule (PDF, 1 page, 70KB)
Positive TB Skin Test (TST) Reporting Form: please phone 1-800-265-7293 ext. 4752 to request a copy

Fax applications to our secure Reportable Diseases fax line: 1-855-WDG-LINE (1-855-934-5463).

Daily Outbreak Line Listing Fax Cover Sheet (PDF, 1 page, 104 KB)
Enteric Outbreak Line Listing (PDF, 1 page, 140 KB)
Respiratory Outbreak Line Listing (PDF, 1 page, 827 KB)
Thermometer Order Form (PDF, 1 page, 132 KB)
Vaccine Order Form (PDF, 1 page, 243 KB)
Vaccine Return Form (PDF, 1 page, 439 KB)

Chlamydia Treatment Request for Information Fax Sheet (PDF, 1 page, 101 KB)
Gonorrhea Treatment Request for Information Fax Sheet (PDF, 1 page, 101 KB)
Confidential Hepatitis B Questionnaire (PDF, 2 pages, 1.7 MB)
Follow-up Reporting Form for Infants Born to Hepatitis B+ Mothers (PDF, 1 page, 189 KB)
STI (Sexually Transmitted Infection) Medication Order Form (PDF, 1 page, 91 KB)
STI (Sexually Transmitted Infection) Medication Log (PDF, 1 page, 76 KB)
Syphilis Treatment Letter (PDF, 2 pages, 126 KB)