Long Term Care Facility Reporting Form

JCHD Long Term Care Facility Reporting Form

Long Term Care Facilities should use this form to report any employees and/or residents with a reportable disease or an outbreak to the Jackson County Health Department.

Please contact the Communicable Disease Nurses with any questions.
Jana Snider, 517-788-4655, jsnider@mijackson.org
Tracy Payne, 517-788-4655, tpayne@mijackson.org

1. Facility Contact Information

Name of Facility

Address

Contact Name

Contact Number

Contact Email This question requires a valid email address.

2. What disease are you reporting on?

Please enter an 'other' value for this selection.

3. Provide any information that you may already know about potential sources of exposure and/or spread.

4. Upload a building schematic and/or line list indicating the resident rooms of positive cases. This can also be faxed to the JCHD secure fax at 517-788-4256.

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