Use this form if you wish to report severe pulmonary disease associated with e-cigarette use to MDH for your patient.

Privacy Information

  • Your decision whether or not to complete this survey does not affect your current or future relationship with the Minnesota Department of Health.
  • You may leave any question blank.
  • All personal information is kept confidential at the Minnesota Department of Health, and only our staff and public health staff responsible for regulating establishments reported in this form have access to this data.
  • Some questions are marked as "required" as the answer to these are necessary for our staff to know for a useful report.

Generally, it takes around 10 minutes to fill out a complete report.

If you would prefer, we are happy to talk with you on the phone at 1-651-201-5640.

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