Health Department Illness Outbreak Report Form - Schools or Early Learning Center

Health Department Illness Outbreak Report Form: Schools and Early Learning Centers
About the Illness Outbreak Report Form:

This form is to be submitted at the Start and End of an illness outbreak at your school or early learning center.

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 disschools@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 End of an outbreak? Definitions of outbreak start and outbreak end are below.*

Outbreak StartOutbreak End

Outbreak Start:

An outbreak is defined as when there are more cases of a disease than what is usually expected within a specific time and location.

An outbreak may be occuring if:

1.	Several children exhibit similar symptoms and are in the same classroom, area of the facility, or attended a common event.
2.	There is an increase in school absences with many parents/guardians reporting similar symptoms as the reason why their child is not attending school.
3.	Two or more students are diagnosed with the same reportable diseases (for example: pertussis, chickenpox, salmonella, etc.)

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Outbreak End:

Generally, an outbreak is considered over when there are no new cases identified for two incubation periods. Incubation periods are different based on the specific disease.

School or Learning Center Information
Today's Date*

MonthDayYear
Date
Name of School*
School Address*

Street Address

Street Address Line 2

CityState

Zip Code
Please select which best describes the school type*

High SchoolMiddle School / Jr. High SchoolElementary SchoolDaycare or Early Learning CenterOther
Name of School Nurse or Point of Contact*

First NameLast Name
Job Title
Phone Number of School Nurse or Point of Contact*
Please enter a valid phone number.
Email Address of School Nurse or Point of Contact*
example@example.com

	Influenza A	Influenza B	Influenza Other/Unknown
Cases among Students
Cases among Residents

	Influenza A	Influenza B	Influenza Other/Unknown
Cases among Students
Cases among Residents

Health Department Illness Outbreak Report Form: Schools and Early Learning Centers

School or Learning Center Information

Outbreak Information