Outbreak Reporting Form
for Institutions/HealthCare

If you are reporting an outbreak associated with gastrointestinal (GI) illness or Influenza, do not use this form and please complete the respective GI Illness or Inflluenza Illness forms.


Facility Name:Facility Type:Specify Facility Type if "Other"
Address:City:
County:Postal Code:Phone Number:
Name of Reporter:Email:
 
Total number of clients in the unit/wing/ward at time of outbreak?Total number of clients in the unit/wing/ward involved in outbreak?
Total number of staff in the unit/wing/ward at time of outbreak?Total number of staff in the unit/wing/ward involved in outbreak?
Number Hospitalized?
Number of Deaths?
Date first case became ill:
Duration of outbreak (length in days)*
Explain suspected etiology of outbreak (ex., Cdiff, MRSA, scabies, etc.)
If etiology unknown, describe relevent finds and symptoms
On your initial investigation/identification of outbreak:
Is equipment suspected as source?
Was a device suspected or identified?
Suspect antibiotic use playing role in outbreak?
Is breech of Infection Control policy suspected?
Is outbreak contained to a certain location?
Are any staff suspected in source of outbreak?
Were you able to identify first case in outbreak?
Were all cases active infections?
 
Have specimens been sent to a laboratory for confirmation?
Have any clients been sent to
another facility/provider for further care?
What sort of measures have your facility
taken in response to the outbreak
(e.g., eating in rooms, decreased activities,
visitor restrictions, isolation type)?
Please list the name of the disinfectant used
for non-porous, hard surfaces, including
the concentration used and frequency of cleaning.
Were any screenings done on cases prior to the outbreak?