Line list - Maryland
Line Listing for Respiratory Illness Outbreaks
List for: Residents/patients____ Employees____ (check one) Unit+:__________________
Name of Facility:__________________________________ Address:____________________________________
Contact Person:___________________________________ Telephone:__________________________________
| | | | | | |Signs and symptoms | | | | |Laboratory results | | | | |
Name
NAME |Age
|Sex
|Room No. or Shift* & Unit*
|Date of Onset
|Duration of Illness
|Fever (Record highest temp.)
|Cough
|Sore Throat
|Runny Nose
|Congestion - Nasal
|Congestion - Chest
|Shortness of breath |Muscle Aches
|Vomiting |Diarrhea
|Pneumonia
|X-ray Results (if taken)
|Hospitalized
Y/N |Death (Date)
|Influenza PCR
|Influenza Rapid Antigen
(Date)
|Bacterial sputum culture |Legionella urine antigen
|Other ____________
|Antiviral if given (Date)
|Influenza Vaccine Y/N (Date) |Pneumococcal Vaccine Y/N (Date)
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+ Use a separate line list for residents on each unit, if possible.
*List shift and unit (or ward) for employee cases
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