LTCF Reporting Form

Facility Information

Use this Long-Term Care/Residential Care Report Form to report any employees and/or residents with a reportable disease or an outbreak to the Livingston County Health Department.

Questions can be directed to:
Lynn Hermann | Epidemiologist | 517-552-6838 | lhermann@livgov.com
Kristen Flory | Communicable Disease Coordinator | 517-552-6837 | kflory@livgov.com

Provide the following information about the FACILITY: *This question is required.

Name of Residential Care Facility
Address
Contact Name
Contact Phone Number
Contact Email

What disease/condition are you reporting?
Please only submit one disease/condition per report. *This question is required.

Please enter an 'other' value for this selection.

Provide any information that you may already know about potential sources of exposure and/or spread. (e.g., staff exposed at home, residents eat dinner together, exposed by visiting family member, etc.).

Upload a Building Schematic, indicating resident rooms of positive cases. This can also be faxed to the LCHD secure fax at: 517-545-9685 or emailed to lhermann@livgov.com.

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Are you reporting an EMPLOYEE or RESIDENT? *This question is required.

If you are reporting both EMPLOYEES and RESIDENTS, please select "EMPLOYEE"

How many EMPLOYEES do you need to report? This question requires a valid number format.