Respiratory Illness Outbreak Facility Reporting

Respiratory Illness 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 here.

Where did the outbreak happen?*

School

Childcare

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

Homeless Resource Center

Other

What disease are you reporting for?*

Influenza

RSV

COVID

Other/Unknown Respiratory Illness

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

Email:

Description of other setting:

Do you know the date that the first illness began?

Yes

No

Date the first illness began:

Residents

Students

Children

Guests

Total number in the facility:

Number ill:

Number hospitalized:

Number died:

Number tested:

Number tested positive:

Number treated:

Number ill vaccinated:

Staff

Total number in the facility:

Number ill:

Number hospitalized:

Number died:

Number tested:

Number tested positive:

Number treated:

Number ill vaccinated:

Infection Control

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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