Cluster & Facility Outbreak Notification Report Form

1. Is this an Initial or Final Report? *This question is required.

2. Type of Outbreak: *This question is required.

Please enter an 'other' value for this selection.

3. Person Providing Report: *This question is required.

Name
Email

Phone
Alt. Phone

4. Facility Information: *This question is required.

Facility Name
Facility Contact Person
Phone number

Address
Affected Unit(s)/Floor(s)

5. Type of Facility *This question is required.

Please enter an 'other' value for this selection.

6. Epidemiology Information: *This question is required.

Onset Date of First Case
Date of Last Onset
Duration (range, average):
Incubation Period (range, average):
Suspected Etiology:

7. Epidemiology Data: *This question is required.

	Initial Case Count	Final Case Count
	Initial Case Count	Final Case Count	Adults	Initial Case Count	Final Case Count
Children	Initial Case Count	Final Case Count
Symptomatic employees	Initial Case Count	Final Case Count
Symptomatic food handlers	Initial Case Count	Final Case Count
Total symptomatic employees	Initial Case Count	Final Case Count
Symptomatic residents/patients	Initial Case Count	Final Case Count
Symptomatic visitors	Initial Case Count	Final Case Count
Total population	Initial Case Count	Final Case Count
Number of hospitalized cases	Initial Case Count	Final Case Count
Number of secondary case	Initial Case Count	Final Case Count
Deaths	Initial Case Count	Final Case Count

8. Symptom Presentation: *This question is required.

	Yes	No	Number of Cases with Symptom	Total # of Cases with Information Available
	Symptom Present?		Number of Cases with Symptom	Total # of Cases with Information Available
Vomiting	Vomiting: Symptom Present?: Yes	Vomiting: Symptom Present?: No	Number of Cases with Symptom	Total # of Cases with Information Available
Diarrhea	Diarrhea: Symptom Present?: Yes	Diarrhea: Symptom Present?: No	Number of Cases with Symptom	Total # of Cases with Information Available
Nausea	Nausea: Symptom Present?: Yes	Nausea: Symptom Present?: No	Number of Cases with Symptom	Total # of Cases with Information Available
Abdominal Cramps	Abdominal Cramps: Symptom Present?: Yes	Abdominal Cramps: Symptom Present?: No	Number of Cases with Symptom	Total # of Cases with Information Available
Fever (highest recorded)	Fever (highest recorded): Symptom Present?: Yes	Fever (highest recorded): Symptom Present?: No	Number of Cases with Symptom	Total # of Cases with Information Available
Bloody Stools	Bloody Stools: Symptom Present?: Yes	Bloody Stools: Symptom Present?: No	Number of Cases with Symptom	Total # of Cases with Information Available
Respiratory (e.g., coughing, wheezing)	Respiratory (e.g., coughing, wheezing): Symptom Present?: Yes	Respiratory (e.g., coughing, wheezing): Symptom Present?: No	Number of Cases with Symptom	Total # of Cases with Information Available
Pneumonia	Pneumonia: Symptom Present?: Yes	Pneumonia: Symptom Present?: No	Number of Cases with Symptom	Total # of Cases with Information Available
Rash	Rash: Symptom Present?: Yes	Rash: Symptom Present?: No	Number of Cases with Symptom	Total # of Cases with Information Available
Itching	Itching: Symptom Present?: Yes	Itching: Symptom Present?: No	Number of Cases with Symptom	Total # of Cases with Information Available
Skin and soft tissue wound/damage	Skin and soft tissue wound/damage: Symptom Present?: Yes	Skin and soft tissue wound/damage: Symptom Present?: No	Number of Cases with Symptom	Total # of Cases with Information Available

9. Any other Symptoms? *This question is required.(if not listed above)

Enter the other symptoms.

Space Cell	Number of Cases with Symptom	Total # of Cases with Information Available
Enter another option	Other: Number of Cases with Symptom	Other: Total # of Cases with Information Available
Enter another option	Other: Number of Cases with Symptom	Other: Total # of Cases with Information Available
Enter another option	Other: Number of Cases with Symptom	Other: Total # of Cases with Information Available
Enter another option	Other: Number of Cases with Symptom	Other: Total # of Cases with Information Available
Enter another option	Other: Number of Cases with Symptom	Other: Total # of Cases with Information Available

10. Specimen Reporting: *This question is required.

	Type of Specimen	No. of Specimens Collected	Test Ordered	Laboratory Performing Tests	Shipping Date (mm/dd/yyyy)	Results
	Type of Specimen	No. of Specimens Collected	Test Ordered	Laboratory Performing Tests	Shipping Date (mm/dd/yyyy)	Results	Entry 1	Type of Specimen	No. of Specimens Collected	Test Ordered	Laboratory Performing Tests	Shipping Date (mm/dd/yyyy)	Results
Entry 2	Type of Specimen	No. of Specimens Collected	Test Ordered	Laboratory Performing Tests	Shipping Date (mm/dd/yyyy)	Results
Entry 3	Type of Specimen	No. of Specimens Collected	Test Ordered	Laboratory Performing Tests	Shipping Date (mm/dd/yyyy)	Results
Entry 4	Type of Specimen	No. of Specimens Collected	Test Ordered	Laboratory Performing Tests	Shipping Date (mm/dd/yyyy)	Results
Entry 5	Type of Specimen	No. of Specimens Collected	Test Ordered	Laboratory Performing Tests	Shipping Date (mm/dd/yyyy)	Results
Entry 6	Type of Specimen	No. of Specimens Collected	Test Ordered	Laboratory Performing Tests	Shipping Date (mm/dd/yyyy)	Results
Entry 7	Type of Specimen	No. of Specimens Collected	Test Ordered	Laboratory Performing Tests	Shipping Date (mm/dd/yyyy)	Results

11. Any other type of specimen testing? *This question is required.(if not listed above)

Enter the other type.

Space Cell	No. of Specimens Collected	Test Ordered	Laboratory Performing Tests	Shipping Date (mm/dd/yyyy)	Results
Enter another option	Other: No. of Specimens Collected	Other: Test Ordered	Other: Laboratory Performing Tests	Other: Shipping Date (mm/dd/yyyy)	Other: Results
Enter another option	Other: No. of Specimens Collected	Other: Test Ordered	Other: Laboratory Performing Tests	Other: Shipping Date (mm/dd/yyyy)	Other: Results
Enter another option	Other: No. of Specimens Collected	Other: Test Ordered	Other: Laboratory Performing Tests	Other: Shipping Date (mm/dd/yyyy)	Other: Results

12. Date Prevention and Control Actions Initiated: *This question is required.

13. Consultation Provided: *This question is required.

Environmental cleaning guidelines
Employee restrictions
Visitor restrictions
Specimen collection and submission

Infection control precautions
Patient co-horting, isolation, and restrictions
Closed units to transfers and admits
Other (please specify) Please enter an 'other' value for this selection. * This question is required.

14. Additional Actions and Notifications: *This question is required.

CDC
FDA
USDA
Other (please specify) Please enter an 'other' value for this selection. * This question is required.