Human Algae Illness Reporting Form

Please use this form to report a human illness or death that you think was related to exposure to blue-green algae. If you have questions about this form, please call KDHE - Bureau of Epidemiology and Public Health Informatics at 877-427-7317 or email epihotline@kdheks.gov. Thank you for reporting this incident to us. We are working hard to improve the health of all Kansas residents and visitors.
Please enter today's date.
mm/dd/yyyy:

Please enter the name and address of the person completing the form.
Name:
Street Address:
City:
State:
Zip:

Please select citizen type that describes you best.
  

How can we contact you for follow-up?
Enter at least 1 response.
Home or cell phone:
Work phone:
Email address:

Please enter the name and contact information of the person who became ill.
Name:
Street Address:
City:
State:
Zip:
Home or cell phone:

Please provide the age of the individual who was exposed.
Age:

What is the gender of the person exposed?
  


Where did the exposure occur?
Names of lake or river:
Location on the lake or river:
Town, city or park:
County:

Date of Exposure.
 

Time of exposure.
    

What was the person doing at the time of exposure?

What was the means of exposure?
Inhalation
Skin contact
ingestion
exposure to aerosols
Not sure

For skin contact or rash, please describe the part of the body where exposure occurred.

Did you notice any dead or sick fish or animals in or near the water?
Yes
No

If yes, please describe the dead or sick animals or fish.

Did you notice any unusual smells or odors.
Yes
No

If yes, please describe the odors.
Do Not Know
Earthy/Moldy
Septic/Sulphur
Fishy/Aquarium
Decayed fish
Medicinal/Phenolic/Alcohol
Crude oil/Petroleum
Other 

Please describe the color and clarity of the water.

Do you remember seeing algae mats or a paint-like film on the water?
Yes
No

What symptoms did you or the affected person experience?

How long after the exposure did the symptoms begin?

Please use the checkboxes below to indicate the symptoms.
Do Not Know
Fatigue
Fever
Loss of appetite
Earache or pressure
Headache
Nasal congestion
Sore throat
Cough
Wheezing
Chest tightness
Nausea
Vomiting
Diarrhea
Itching
Skin rash or blistering
Hives

For each symptom listed above, please indicate how long the symptoms persisted. For example, headache-2 days, rash-5 days, etc.

Did you see a doctor or nurse regarding these symptoms?
Yes
No

If yes, what treatment did you receive?


Any additional information or comments:



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