Health Department Illness Outbreak Report Form

Health Department Illness Outbreak Report Form
About the Illness Outbreak Report Form:

This form is to be submitted at the Start and End of an illness outbreak at your facility.

Once submitted, the Disease Investigation and Surveillance (DIS) Team will reach out and conduct regular check-ins regarding the ongoing outbreak.

A line list is required for all outbreaks, excluding COVID-19, influenza, and RSV. For your convenience, a line list template is available at the link below. The completed line list can be uploaded at the end of this form.

Link to Line List Template

If you have any questions, please contact the Disease Investigation and Surveillance Team via email at congregatecare@chesco.org

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Are you reporting an outbreak of 1). Gastrointestinal illness; 2). COVID-19, Influenza, or RSV; or 3). Other or Unknown?*

GastrointestinalCOVID-19, Influenza, or RSVOther or Unknown
Are you reporting an outbreak of COVID-19, Influenza, or both? Note: RSV outbreaks are not independently tracked and cases should only be reported when occurring simultaneously with another outbreak, such as Influenza or COVID-19.*

COVID-19InfluenzaBoth
Are you reporting the Start or the End of an outbreak? Definitions of outbreak start and outbreak end are below.*

Outbreak StartOutbreak End

Outbreak Start:

The definition of the start of an outbreak is different by disease. Please review the disease-specific defintions below.

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Defintions of Outbreak Start:

GI Illness	2 or more similar GI illnesses resulting from a common exposure or within a time period that is atypical for the facility.
COVID-19	2 or more facility-aquired probable or confirmed cases of COVID-19 in residents in a single unit within a 7-day period OR 2 or more probable or confirmed of COVID-19 in health care personnel who were working in the same unit while infectious within a 7-day period
Influenza	1 resident with laboratory-confirmed influenza AND 1 or more additional residents with Influenza-like illness (ILI) OR 2 or more residents with Influenza-like illness (ILI) within 72 hours of each other *Influenza-like Illness (ILI) is fever (>=100°F) with a new cough or sore throat
RSV	RSV outbreaks are not independently tracked and cases should only be reported when occurring simultaneously with another outbreak, such as Influenza or COVID-19.

Outbreak End:

The defintion of the end of an outbreak is different by disease. Please review the disease-specific defintions below.

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Defintion of Outbreak End:

An outbreak is considered over when there have been 0 new cases for

Gastrointestinal:	7 days
COVID-19:	14 days
Influenza:	14 days

RSV: RSV outbreaks are not independently tracked and cases should only be reported when occurring simultaneously with another outbreak, such as Influenza or COVID-19.

Facility Information
Today's Date*

MonthDayYear
Date
Name of Facility*
Facility Address*

Street Address

Street Address Line 2

CityState

Zip Code
Please select which best describes the facility type*

Skilled NursingPersonal Care HomeAssisted LivingRehabilitation CenterOther
Name of Facility Point of Contact*

First NameLast Name
Job Title
Phone Number of Facility Point of Contact*
Please enter a valid phone number.
Email Address of Facility Point of Contact*
example@example.com
Current Resident Census*
Number of residents currently in facility
Current Staff Census*
Number of staff currently working at facility

	Were diagnosed with COVID-19	Were hospitalized due to COVID-19	Died due to COVID-19
Number of Residents
Number of Staff

	Influenza A	Influenza B	Influenza Other/Unknown
0-4 years of age
5-9 years of age
10-18 years of age
19-24 years of age
25-49 years of age
50-64 years of age
65+ years of age
Unknown

	Influenza A	Influenza B	Influenza Other/Unknown
0-4 years of age
5-9 years of age
10-18 years of age
19-24 years of age
25-49 years of age
50-64 years of age
65+ years of age
Unknown

	COVID-19
Cases among Residents
Cases among Staff

	RSV
Cases among Residents
Cases among Staff

	RSV
Cases among Residents
Cases among Staff

Health Department Illness Outbreak Report Form

Facility Information

Outbreak Information