Tickborne Disease Case Report Form

This form can be used to report anaplasmosis, babesiosis, ehrlichiosis, Lyme disease, and spotted fever rickettsiosis (including typhus).

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

Tickborne form

• Tickborne Disease Case Report Form (PDF)
  Updated 7/2012
  

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.
  

Returning the completed form

• 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

• Lyme Disease (Borrelia burgdorferi, and other Borrelia spp.)
• Babesiosis (Babesia spp.)
• Anaplasmosis (Anaplasma phagocytophilum)
• Ehrlichiosis (Ehrlichia spp.)
• Spotted fever rickettsiosis (Rickettsia spp. infections, including Rocky Mountain spotted fever)