Facility Name:

Facility Type:

Please select a facility Long Term Care Assisted Living Basic Care Child Care/Pre-school Group Home Educational Institution Correctional Facility Work-place Shelter Other

Address:

City:

County:

Zip Code:

Phone Number:

Place select a county Adams Barnes Benson Billings Bottineau Bowman Burke Burleigh Cass Cavalier Dickey Divide Dunn Eddy Emmons Foster Golden Valley Grand forks Grant Griggs Hettinger Kidder La Moure Logan McIntosh McHenry McKenzie McLean Mercer Morton Mountrail Nelson Oliver Pembina Pierce Ramsey Ransom Renville Richland Rolette Sargent Sheridan Sioux Slope Stark Steele Stutsman Towner Traill Walsh Ward Wells Williams

Name of Reporter:

Email:

Total number of residents in the facility at time of outbreak?

Total number of residents in the facility with influenza-like illness?

Total number of staff in the facility at time of outbreak?

Total number of staff in the facility with influenza-like illness?

Date of symptom onset for the first case of ILI during outbreak:

From the symptoms below, please indicate the five most common symptoms associated with this outbreak:

Cough

Coryza (runny nose)

Chills

Nausea

Fever

Myalgia (body ache)

Rash

Headache

Earache

Stomach ache

Sore Throat

Have specimens been sent to a laboratory for confirmation?

Yes

No

If yes, list the name of the laboratory

What is the vaccination status of the ill

residents in your facility?

Has any antiviral medicine been given to

the residents in your facility?  If yes please

include date.

What sort of measures has your facility taken in

response to the outbreak (e.g. eating in rooms,

decreased activities, visitor restrictions)?