Confidential GI Illness Outbreak Reporting Form
for Institutions

SFN 58506 (Non-respiratory illness; 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/patients/students in the facility at time of outbreak?Total number of residents/patients/students with gastroenteritis?
Total number of staff employed at the facility at time of outbreak?Total number of staff with gastroenteritis?
Total number of food workers with gastroenteritis?
Date first case became ill:
Date last case became ill:
Duration of outbreak (length in days)*
*If the outbreak is ongoing, please submit a final report with updated numbers once the outbreak is over.
Is this a final report?
From the list below, please indicate the most common signs or 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, please list the name of the facility
 Number hospitalized
 Number of deaths
What measures has 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.

If you have any questions, please contact the NDDoH Division of Disease Control at 800.472.2180 or 701.328.2378.