Wisconsin Department of Health Services

Time Elapsed: 0 minutes Time Remaining: 0 minutes Total Time: 0 minutes Anonymous Login Code: Save this code, which is required to update your response at a later time.   Page 1 of 1     Algae-Related Illness Report Form      Please use this form to report a human or animal illness or death that you think was related to exposure to blue-green algae. If you have questions about this form, please call Emmy McAuliff at 608-267-3242 or email her at emelia.mcauliff@wi.gov. Thank you for reporting this incident to us. We are working hard to improve the health of all Wisconsin residents and visitors.      1. Please enter today's date   mm/dd/yyyy     2. Please enter your name and address   Name   Street Address   City/township name, State, Zip       3. Are you reporting on a HUMAN or ANIMAL illness?   --None--HumanAnimalNeither     4. If you are reporting an animal illness or death, please describe the incident and complete the water quality questions below. Someone will contact you for additional information.       5. Where did the exposure occur?   Name of lake or river   Location on the lake   Town, city or park   County       6. Please select the choice that describes you best   --None--CitizenHealth department employeeHealth care providerVeterinarianOther     7. How can we contact you for follow-up? Enter at least 1 response and no more than 3 responses.   Home or cell phone number   Work phone number   Email address       8. Please provide the age of the individual who was exposed.       9. What is the gender of the person exposed? *   --Please Select--MaleFemale     10. Which racial/ethnic group(s) best describes the exposed individual.   White Black/African American Asian Hawaiian or Pacific Islander Native American Hispanic Other     11. Date of exposure   mm/dd/yyyy     12. Time of exposure       13. Please describe what you were doing at the time of exposure       14. What was the route of exposure?   Inhalation Skin contact Ingestion Exposure to aerosols Not sure     15. For skin contact or skin rash, please describe the part of the body affected.   Part of body affected       16. Did you notice any dead or sick fish or animals near the water?   --None--Yes No     17. If yes, please describe the dead or sick animals or fish.       18. Did you notice any unusual smells or odors?   --None--Yes No     19. If yes, please describe the odors.       20. Please describe the color and clarity of the water.       21. Do you remember seeing algal mats or a paint-like film on the water?   --None--Yes No     22. What symptoms did you or the affected person experience?       23. How long after the exposure did the symptoms begin?       24. Please use the checkboxes below to indicate your symptoms.   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     25. For each symptom listed above, please indicate how long the symptom persisted. For example, headache-2 days, rash-5 days, etc.       26. Did you see a doctor or nurse regarding these symptoms?   --None--Yes No     27. If yes, what treatment did you receive?

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