Communicable Disease Control Order Form

  • MM slash DD slash YYYY
  • To End user:

  • Based on your positive test result of a communicable disease: novel coronavirus disease, known as COVID-19, you are being issued this control order. Your local health department is the Wichita Falls-Wichita County Public Health District. You can contact them at 940-761-7800 twenty-four hours a day, seven days a week. Under the authority of Texas Health and Safety Code §81.083 you are hereby ordered to implement the following control measures, effective immediately, that are reasonable and necessary to prevent the introduction, transmission, and spread of this disease in this state:

  • (Please confirm your understanding by initialing each paragraph.)

  • ISSUED PURSUANT TO MY AUTHORITY AS THE ACTING LOCAL HEALTH AUTHORITY FOR THE WICHITA FALLS-WICHITA COUNTY PUBLIC HEALTH DISTRICT DATED ON THE DATE AS INDICATED ABOVE.

  • Arthur J. Szczerba, M.D., C.M.D., F.A.A.F.P.

  • Medical Director, Wichita Falls-Wichita County Public Health District

  • Local Health Authority, Wichita County

  • Certificate of Service

    I, _________________, hereby certify that the foregoing Control Order was served by the following:
  • Lou's Signature HERE

  • Acknowledgement of Receipt

    I, ___________________, hereby acknowledge receipt of this Control Order on __________________.
  • E-Signature

    I agree hereby acknowledge receipt of this Control Order on the date indicated above.