Influenza Outbreak Facility Reporting

Influenza Outbreak Facility Reporting

Please report the following information when there are two or more ill residents within 72 hours of each other, and one or more of them has laboratory-diagnosed influenza.
All ill residents and staff should be reported.
Call 385-468-4194 with any questions.
CDC toolkit for long-term care centers can be found at https://www.cdc.gov/flu/toolkit/long-term-care/index.htm

Where did the outbreak happen?

School

Childcare

Group Living (Rehabilitation Center, Assisted Living, etc.)

Homeless Resource Center

Other

Facility Information

Please select which Homeless Resource Center:

Gail Miller Resource Center (The Road Home)

Midvale Family Resource Center (The Road Home)

Men's Resource Center (The Road Home)

Geraldine E. King Women's Resource Center (Volunteers of America)

Youth Resource Center (Volunteers of America)

Rescue Mission - Men's Center

Rescue Mission - Women's Center

Weigand Resource Center (Catholic Community Services)

Name of facility:*

Address of facility:*

Name of person filling out form:*

Phone number:*

Phone

Description of other setting:

Residents

Students

Children

Guests

Total number:

Number ill:

Number hospitalized:

Number died:

Number tested:

Number tested positive:

Number treated:

Number ill vaccinated:

Staff

Total number:

Number ill:

Number hospitalized:

Number died:

Number tested:

Number tested positive:

Number treated:

Number ill vaccinated:

Infection Control

Infection Control (check all that apply)

All residents with confirmed or suspected influenza were isolated with Standard and Droplet Precautions.

All eligible residents in the entire facility (not just currently in the impacted wards) were given antiviral chemoprophylaxis as soon as the outbreak was determined.

Confidential Case Reporting Form

Upon clicking "Submit", you will be directed to another form to report individual positive results.

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