Reporting Disease Outbreaks

Reporting Disease Outbreaks

to Lincoln County Health Department in Wisconsin
After completing this form, you are required to call Lincoln County Health Department and speak to a live person at 715-536-0307 to notify them you have completed this form for an outbreak, if you have not already.

If it is a weekend, holiday, or after 4:30pm Monday-Friday, after completing this form, call the Lincoln County Sheriff's Department at 715-536-6272.

A suspected outbreak in a Long Term Care Facility and Assisted Living settings to report to us, is defined as:
- 3 or more residents and/or staff from the same unti with illness onsets within 72 hours of each other for respiratory or gastrointestinal illness.
Please note, this is Step 1 of reporting a disease outbreak. After completing this form and calling the health department (if you have not yet), you will be asked to complete a line list of ill staff and residents or if single person, close contacts.
Initial Report Contact Information:
Today's Date

MonthDayYear
Date
Current Time:
Reason for reporting:
Example: Influenza outbreak, etc.
Facility/Person Name:
Facility Contact:
Facility contact
Contact Phone Number:
Format: (000) 000-0000.
Contact Email:
example@example.com
Contact Fax:
Facility Street Address
Type of Facility:
Information & Data on Report
Current Number of Residents Ill:
Number of Residents Exposed:
Ex: # of residents exposed in wing/unit/floor
Current Number of Staff Ill:
Number of Staff Exposed:
Ex: # of staff exposed in wing/unit/floor
Earliest Onset Date of Resident:

MonthDayYear
Date first resident became ill.
Earliest Onset Date of Staff:

MonthDayYear
Date first staff person became ill.
Number Hospitalized (include name and which hospital):
If applicable.
Units affected:
If applicable.
Duration of Illness:
Symptoms:
Symptoms ill staff or residents are experiencing.
Has lab work been completed to confirm illness?
If yes, what is your method of testing? Include results, date, and lab location.
Was prophylaxis administered? If so, list name of medication and who treated:
Any large events or parties in the past 2 weeks? If yes, where and when?
Additional Comments:
Should be Empty:

Reporting Disease Outbreaks

Initial Report Contact Information:

Information & Data on Report