Arboviral Disease Case Report Form

This form can be used to report chikungunya virus disease, Eastern equine encephalitis, Jamestown Canyon virus disease, La Crosse encephalitis, Powassan virus disease, St. Louis encephalitis, West Nile virus, Western equine encephalitis, yellow fever, Zika virus disease and other arboviral diseases.

On this page:
Arboviral form
Frequently asked questions 
Returning the completed form 
Diseases to report on this form

Arboviral form

• Arboviral Disease Case Report Form (PDF) 
  Updated 2015
   

Frequently asked questions

• If you have questions regarding this form, please call 651-201-5414.
   
• When reporting on this form, a Yellow Card is not necessary.
   
• Please do not report Malaria on the arboviral report form, use the disease-specific form: Malaria Case Report Form
  This form can be used to report Malaria (Plasmodium spp.) to the Minnesota Department of Health. Please report all patients (symptomatic or asymptomatic) who test positive for Plasmodium species.

Returning the completed form

After filling out this form, please return to MDH:

• By mail (please mark the envelope "confidential") to:
  Infectious Disease Epidemiology, Prevention and Control
  625 North Robert Street
  Post Office Box 64975 
  St. Paul, MN 55164-0975 
   
• By fax to:
  1-800-233-1817

Diseases to report with this form

• Arboviral Disease
• Chikungunya virus disease
• Yellow fever
• Zika virus disease