Outbreak Reporting Form
Facility name
Today's date
-
Month
-
Day
Year
Date
Name of person filling out form
First Name
Last Name
Email of person filling out form
example@example.com
Phone number of person filling out form
Please enter a valid phone number.
Name of ill individual
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Age
Gender
Please Select
Female
Male
Other
Unknown
Pathogens
Acute Gastrointestinal Illness (AGI)
Acute Respiratory Illness (ARI)
COVID-19
Influenza
Norovirus
Other
Setting
Assisted living
Catered event/wedding
Community
Day care/preschool
Food establishment
Group house
Hospital
Independent living
K-12 school
Long term care
Other
Position of ill individual
Please Select
Staff member
Client/resident/attendee
Community member
If staff, last day worked
-
Month
-
Day
Year
Date
Symptoms (only required for GI illnesses)
Diarrhea
Vomiting
Fever
Cough
Rash
Date onset of symptoms
-
Month
-
Day
Year
Date
Testing
Lab confirmed
Rapid test
Suspected or epi-linked
Other
Date tested
-
Month
-
Day
Year
Date
Control measures
Assigned staff to sections
Case isolation
Cohort ill residents
Contact tracing
Educational materials provided
Environmental cleaning
Environmental testing
Group activities cancelled
Hygiene education
Prophylaxis
Sample collection
Staff exclusion
Training
Visitor restrictions
Ward/school closure
Other
Date control measures implemented
-
Month
-
Day
Year
Date
Number of staff exposed
Number of clients exposed
Number of community members exposed
Health outcome of ill individual
Healthcare visit (primary or urgent care)
ER visit
Admitted to healthcare facility
Deceased
Additional comments/updates
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