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Varicella Sentinel Surveillance System ­ Enrollment
State Form 51848 (7-04)

Indiana State Department of Health ­ Epidemiology Resource Center

Type of Enrollee:

Physician's Office

School

Day Care

Name of Enrollee (practice, school, day care): Street Address of Practice, School, Day Care: City: Telephone Number of Practice, School, Day Care: Fax Number of Practice, School, Day Care: E-mail Address: Name of Primary Person Responsible for Reporting: Telephone Number of Primary Person (if different from general number listed above): (include Area Code) State: IN ZIP Code:

(include Area Code)

(include Area Code)

Upon receipt of the enrollment form, the Indiana State Department of Health (ISDH) will send confirmation of enrollment along with the monthly reporting form, ISDH Varicella Disease Surveillance Monthly Report. The Varicella Sentinel Surveillance System is a voluntary reporting system for private practice physicians, schools, and day-care centers. Each month, participants should submit a report of all chickenpox cases, including those not directly observed but reported by the patient or parent/guardian. The report should be submitted using the ISDH Varicella Disease Surveillance Monthly Report. Please return the completed enrollment form to:
Wayne Staggs, Epidemiologist Epidemiology Resource Center Indiana State Department of Health 2 North Meridian Street Indianapolis, Indiana 46204 Phone: 317.233.7112 (voice) 317.234.2812 (fax) E-mail: [email protected]