Measles Contact Report

The purpose of this form is to promptly identify individuals who have been exposed to measles in a public setting in Shelby County, Ohio.  The Sidney-Shelby County Health Department may reach out to you to provide additional information and guidance.  All information provided is voluntary and will only be used in the context of preventing the spread of disease.  Always seek the advice of your doctor or a professional healthcare provider regarding your personal medical situation.  Using this form does not create a doctor-patient relationship.

Note to parents: Please complete a separate entry for everyone who was exposed to measles.

Measles Contact Report Form

Exposure Location

Exposure Date

Name

First Name

Last Name

Date of Birth

Age

Sex

Parent or Guardian First and Last Name (if under 18)

Address

County

Phone

Alternative Phone

Name of school or daycare if attends or associated with a school/daycare:

School or daycare phone number

Have you had at least one dose of MMR Vaccine?

Yes

Unknown

Do you have proof of immunity? (Documentation of history of measles or a test result)

Yes

Do you have a weakened immune system from an immune compromising medical condition, treatments, or medications?

Yes

Unknown

Primary Care Provider Name

Primary Care Provider Phone

If you are human, leave this field blank.

Measles Contact Report

Measles Contact Report

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