Epi-1 Request Form

Non-laboratory healthcare facilities wishing to report cases of disease to their local health department should complete and mail an Epi-1 form.  If your facility currently does not have any Epi-1 forms for reporting or is running low, please complete and submit the form below.  You should receive your request by mail within one business week.

Facility Name*: 

Street Address*:

Name of person filing request:

Please Select How Many Forms Your Facility Needs*:

10
25
50
100
200

Comments: