Please use this form to report cases of varicella to Dallas County Health and Human Services. Fax weekly to 214-819-6095 or mail to 2377 N. Stemmons Frwy., Ste. 522, Dallas, TX 75207.

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LAST NAME	FIRST	DOB	SEX M --- F	RACE
ADDRESS	CITY	ZIP CODE	HISPANIC? YES ----- NO

ONSET DATE ___/___/______
LAST NAME	FIRST	DOB	SEX M --- F	RACE
ADDRESS	CITY	ZIP CODE	HISPANIC? YES ----- NO

ONSET DATE ___/___/______
LAST NAME	FIRST	DOB	SEX M --- F	RACE
ADDRESS	CITY	ZIP CODE	HISPANIC? YES ----- NO

ONSET DATE ___/___/______
LAST NAME	FIRST	DOB	SEX M --- F	RACE
ADDRESS	CITY	ZIP CODE	HISPANIC? YES ----- NO

REPORTED BY: ___________________________	PHONE: _________________________
CITY: ____________________________________	COUNTY: ____________________________

TEXAS DEPARTMENT OF HEALTH, IMMUNIZATION DIVISION

01/2001