Facility Cluster Outbreak Report

1. Facility Information:

	Today's Date (MM/DD/YYYY)
	Name of Facility
	Name of Person Completing Form
	Phone Number of Person Completing Form
	Email of Person Completing Form
	Name of Contact Person (If Different than Person Completing the Form)
	Contact Phone Number (If Different than Person Completing the Form))
	Contact Email (If Different than Person Completing the Form)
	Affected Unit/Floor

2. Facility Type: