HAI Outbreak Reporting Form

	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:

Have specimens been sent to a laboratory for confirmation?	YesNo
Have any clients been sent to another facility/provider for further care?	YesNo
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?	YesNo

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?	YesNo
Was a device suspected or identified?	YesNo
Suspect antibiotic use playing role in outbreak?	YesNo
Is breech of Infection Control policy suspected?	YesNo
Is outbreak contained to a certain location?	YesNo
Are any staff suspected in source of outbreak?	YesNo
Were you able to identify first case in outbreak?	YesNo
Were all cases active infections?	YesNo