Influenza-Like Illness Outbreak Form

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

Nausea

 

Fever

Myalgia (body ache)

Rash

Headache

 

Earache

Stomach ache

Sore Throat

 

 

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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)?