Influenza-Like Illness Outbreak Form

Also check out the NDDoH LTC ILI Oubreak Checklist

For outbreaks of gastrointestinal illess (diarrhea, nausea, vomiting, etc.), please complete the GI Outbreak Reporting Form for Institutions

Facility Name:

Facility Type:

Address:

City:

County:

Zip Code:

Phone Number:

Name of Reporter:

Email:

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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

Conjunctivitis

 

Fever

Myalgia (body ache)

Rash

Headache

 

Earache

Sore Throat

 

 

 

Other Symptoms:

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Have specimens been sent to a laboratory for confirmation?

Yes

No

 

 

 

 

If yes, list the name of the laboratory

 

 

 

If yes, what was the result? (select all that apply)

 

Influenza A

Influenza A H3N2

 

Influenza A 2009 H1N1

Influenza B

 

Rhinovirus/Enterovirus

Coronavirus

 

Adenovirus

Parainfluenza

 

Human Metapneumovirus

RSV

 

Negative

 

Other Result:

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)?