GI Outbreak Reporting Form
for Institutions

SNF 58506  (Non-respiratory; vomiting and/or diarrhea only)
Facility Name:Facility Type:Specify Facility Type if "Other"
Address:City
County:Postal Code:Phone Number
Name of Reporter:Email:
 
Total number of residents in the facility at time of outbreak?Total number of residents in the facility with gastroenteritis?
Total number of staff in the facility at time of outbreak?Total number of staff in the facility with gastroenteritis?
Total number of food workers in the facility with gastroenteritis?
Date first case became ill:
Duration of outbreak (length in days)*
*If ongoing, please also submit a final report at the conclusion of the outbreak with updated numbers.
Is this a final report?
From the symptoms below, please indicate the most common symptoms associated with this outbreak:


Did a noted public vomiting event occur?
Is a foodborne transmission suspected?
 
Have specimens been sent to a laboratory for confirmation?
 If yes, please list the name of the laboratory
 Number of specimens submitted
 List the confirmed agent (ex. norovirus)
Have any residents been transferred to an acute care facility or seen by a physician?
 If yes, list the name of the facility
 Number Hospitalized
 Number of Deaths
What sort of measures have your facility
taken in response to the outbreak
(e.g., eating in rooms, decreased activities, visitor restrictions)?
Please list the name of the disinfectant used
for non-porous, hard surfaces, including
the concentration used and frequency of cleaning.