SCHOOL/DAYCARE CHICKEN POX REPORTING FORM 

Upon notification of each case of chicken pox: 

1. Complete this form. 
2. Form can be found on our website www.wechu.org (search word chickenpox). 
3. Fax completed form to 226 783-2132 (within one business day). 
4. Distribute the “Exposure to Chicken Pox” letter (public health unit will email letter). 
 

Date reported to school/daycare: 

Information obtained from: 

Name of school/daycare reporting: 

Administrator's name: 

Contact number: 

Administrator's email: 

Student date of birth: 

Age: 

Sex: 

Name of student (First Middle Last):

Address (Street City Postal Code):

Name of parent/guardian:

Home phone:

Alternate phone:

Last day attended school/daycare: 

Language spoken at home: 

Collection of information conforms to the Health Promotion and Protection Act, R.S.O. 1990, c. H.7, s. 28 and the Infectious Disease Protocol, 2016. Please contact the Windsor Essex County Health Unit for further information.

*Once Windsor-Essex County Health Unit has confirmed receipt of this fax; please destroy 
this form in a confidential manner. 
  
Reportable Diseases\Chicken Pox/Jan. 2017 lp