Intake Outbreak Form

Chester County Health Department Gastrointestinal Illness Outbreak Reporting Form
Please submit this form at the beginning of an outbreak in a long-term care facility, school, early childhood education center or other congregate care facility. Once submitted, the Chester County Health Department will reach out to you for additional information.
Name of individual filling out form*

First NameLast Name
Please share your job title*
Phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Email address*
example@example.com
Today's date*

MonthDayYear
Date

Chester County Health Department Gastrointestinal Illness Outbreak Reporting Form