• Jackson County Public Health

    Measles Exposure Assessment Form

  • Jackson County Public Health (JCPH) has identified a potential measles exposure at the JCPH facility in Lee's Summit on September 8 and September 10, 2026. In addition, exposures were identified in Overland Park, KS, at Kyoto Sushi and Steak and Pan Asia Supermarket on September 7th, 2026. 

    Please complete one form for each person who was present at these facilities during one or all of the exposure periods listed below. If multiple members of your household or party were present, submit a separate form for each individual.

    The information you provide will help JCPH determine whether additional public health follow-up is recommended based on the individual's exposure, symptoms, vaccination history and other factors.

    If you are currently experiencing symptoms that could be consistent with measles, please do not visit Jackson County Public Health or another healthcare facility without calling ahead first.

    If you are experiencing a medical emergency, seek emergency medical care and notify the facility that you may have been exposed to measles.

  • Person Potentially Exposed

  • Is this form being completed for a child under 18?
  • Relationship to Individual
  • Format: (000) 000-0000.
  • Preferred method of contact
  • Preferred language
  • Do you need an interpreter when speaking with JCPH staff?
  • Were you present at any of these facilities during the dates and times listed below? *Please select if present at any time
  • When were you at the Jackson County Public Health facility? Please select all that apply.
  • Where did you spend time while at JCPH?
  • Did anyone accompany you inside the facility? *

  • Each person who accompanied you should complete a separate exposure assessment form.

  • Are you currently experiencing any of the following symptoms? *Select all that apply.

  • Please do not come to Jackson County Public Health or another healthcare facility without calling ahead.

    A member of the JCPH team will review your information. Ifyou need medical care before speaking with JCPH, call your healthcare providerbefore arriving and tell them that you may have been exposed to measles.
  • When did your first symptom begin?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you currently have a rash?
  • When did the rash begin?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you currently have an fever?

  • The following questions help JCPH determine whether you may need additional or more urgent follow-up after a measles exposure.

  • Do you have a weakened immune system or take medications that suppress your immune system?
  • Are you currently pregnant?
  • Have you ever received a measles-containing vaccine, such as the MMR vaccine?
  • How many doses of MMR or another measles-containing vaccine have you received?
  • Do you have documentation of your vaccination?
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Have you previously had a blood test (titer) showing that you are immune to measles?
  • Do you have documentation of the positive measles immunity test?
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • By submitting this form, I confirm that the information provided is accurate to the best of my knowledge. I understand that Jackson County Public Health may contact me or the parent/guardian listed above to obtain additional information and provide public health recommendations related to this potential measles exposure.

  • Should be Empty: