LTCF Outbreak Reporting

Long-Term Care Facility Outbreak Reporting Form

Please use this form to report any suspected or confirmed outbreak of a communicable disease at your facility to the Kent County Health Department (KCHD). Our team will review the information and follow up with you as needed. Thank you for helping us protect the health of our community!

You do not need to report individual cases of COVID-19. Please only report outbreaks of 3 or more cases.

1. Please provide us with the following information:

Your Name & Job Title
Phone Number
Email Address
Facility Name
Facility Type (e.g. SNF, LTCF)
Facility Address
Date Reporting (today's date)

2. Please indicate the current number of individuals (total residents and staff; including both ill and non-ill) in your facility:

Total # of Residents (both ill and non-ill)
Total # of Staff (both ill and non-ill)

3. What is the known or suspected condition you are reporting?

4. If "Other", please describe:

5. What illness have they been diagnosed with?

5. What is the onset date of the first case? (mm/dd/yyyy)

6. Total number of symptomatic persons (include those with or without confirmed diagnosis):

# of Ill Residents
# of Ill Staff
# of Ill Visitors

8. Are there cases located in a specific building, unit or floor? If yes, please provide additional details: