Name: {{name}}
Organization:
(leave blank if none)		 {{organization}}
Category: {{category}}
Address: {{address}}
Address:
(continued)		 {{address2}}
City: {{city}}
State:
(US Only)		 {{state}}
Zip Code: {{zip}}
Phone: {{phone}}
E-Mail Address: {{email}}
How Did You Find Us: {{howfind}}
 
Date of Outbreak: {{datetime}}
please enter in MMDDYY format
example:  062598
Patient Age: {{ageofpatient}}

Patient Sex:

 {{sexofpatient}}
Where did the outbreak occur?
{{whereoutbreakoccur}}
When did the outbreak occur?
 {{whenoutbreakoccur}}
Describe the type of outbreak (lice or scabies)
and provide any additional notes:
 {{outbreakcomments}}
Does your community/organization have a head lice prevention program? {{campaign}}
Have you used a lice or scabies treatment that failed? {{treatfail}}
Has a lice or scabies treatment caused you harm or made you ill? {{advreac}}
 
Comments: {{comments}}