School Outbreak (Influenza-ILI)
REPORT FORM: OUTBREAK OF INFLUENZA-LIKE ILLNESS (ILI) OR INFLUENZA IN A SCHOOLMDH Outbreak #________________Date of report: ____/____/________ Jurisdiction: _______________________________LHD contact person: ___________________ Facility contact person: _____________________Name of School: _______________________________________________________________Elementary ?Middle ? High ? K-8 ?K-12Public ? PrivateSpecial needs ? Vocational ? Other:__________ Number of students enrolled at the school:Number of staff: School Description:Date the outbreak was first recognized: ____/____/________Absenteeism: Day of report (# or %): ____________ Baseline (# or %):________________Number of health room visits on day of report: Total: _____________ For ILI: __________Special populations affected or clusters identified? YES NOSpecify grades/class, or defined population (e.g., team, club): ______________________________________________ Agent identified: ? Yes ? No ? Unknown ? Clinical diagnosis made by healthcare provider? If Yes: ? Influenza A ? Influenza B ? Type unknown or ? Other: ______________Was school or class dismissed/closed for any days? YES NOIf yes, on what date? ____/____/_______ For how many days? _________Date outbreak ended*: ____/____/________ Optional information:STUDENTS: STAFF:# of cases (TOTAL) FORMTEXT ?????# of cases (TOTAL) FORMTEXT ?????# with lab-confirmed influenza FORMTEXT ?????# with lab-confirmed influenza FORMTEXT ?????# with ILI FORMTEXT ????? # with ILI FORMTEXT ????? # of hospital admissions FORMTEXT ?????# of hospital admissions FORMTEXT ?????List the symptoms and their frequency experienced by cases in this outbreak: __________________________________________________________________________________________________________________________________________________________________________Comments:_______________________________________________________________________________________________________________________________________________________________ ................
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