Natural Disaster Morbidity Surveillance Summary Report Form

For Reporting Purposes

Submit completed form daily to ______via email (), phone (xxx/xxx.xxxx) or fax (xxx/xxx.xxxx)

Natural Disaster Morbidity Surveillance Summary Report Form

For Reporting Purposes

Part III / Persons SEEN OR TREATED
TOTAL SEEN OR TREATED DURING CURRENT REPORTING PERIOD: / #
RACE / ETHNICITY / White / #
Black/African American / #
Hispanic or Latino / #
Asian / #
Unknown / #
age / ≤ 1 years / #
≥ 65 years / #
Pregnant females / #
TOTAL REFERRED TO HOSPITAL: / #
Part I / FACILITY Information
LOCATION:
STATE zIPCODE NAME OF FACILITY
REPORTING PERSON/CONTACT:
PHONE NAME
FAX EMAIL
Part II / REPORTING PERIOD
START: / AM PM
END: / AM PM
MONTH DAY YEAR HOUR (CIRCLE)
TOTAL SHELTER POPULATION AT START: / #
Part IV / TREATED PATIENTS
Use categories that best describe patients’ current reasons for seeking care. Complete the Total patient tallies for each syndrome category in the column to the right. Be as specific as possible. A single patient may be counted more than once.

Natural Disaster Morbidity Surveillance Summary Report Form

For Reporting Purposes

SYNDROME CATEGORY / TOTAL
WORKERS/VOLUNTEERS - TOTAL / ______
INJURY - TOTAL / ______
Fall, slip, trip (from height or same level) / ______
Motor vehicle crash / ______
Carbon monoxide exposure / ______
Violence/assault / ______
Injury - not specified above / ______
DERMATOLOGIC/SKIN - TOTAL / ______
Rash / ______
Infection / ______
Infestation (e.g., lice or scabies) / ______
GASTROINTESTINAL ILLNESS - TOTAL / ______
Diarrhea - bloody / ______
Diarrhea - watery / ______
Nausea or vomiting / ______
OB/GYN – TOTAL / ______
GYN condition not associated with pregnancy or post-partum period / ______
In labor / ______
Pregnancy complication / ______
Routine pregnancy check-up / ______
RESPIRATORY ILLNESS - TOTAL / ______
Congestion, runny nose, sinusitis / ______
Cough / ______
Pneumonia, suspected / ______
Shortness of breath or difficulty breathing / ______
Wheezing in chest / ______
INFLUENZA-LIKE-ILLNESS (ILI) - TOTAL / ______
SYNDROME CATEGORY / TOTAL
OTHER ILLNESS - TOTAL / ______
Dehydration / ______
Fever (≥100o F or 37.8o C) / ______
Meningitis/encephalitis, suspected / ______
Neurological / ______
Pain / ______
Other illness – not specified above / ______
EXACERBATION OF CHRONIC DISEASE - TOTAL / ______
Cardiovascular disease (e.g., hypertension, CHF) / ______
Diabetes / ______
Immunocompromised (e.g., HIV, lupus) / ______
Neurological (e.g., seizure, stroke) / ______
Respiratory (e.g., Asthma, COPD) / ______
MENTAL HEALTH - TOTAL / ______
Agitated behavior / ______
Anxiety or stress / ______
Depressed mood / ______
Drug/alcohol intoxication or withdrawal / ______
Previous mental health diagnosis / ______
Psychotic symptoms (i.e. paranoia) / ______
Suicidal thoughts or ideation / ______
ROUTINE/FOLLOW-UP - TOTAL / ______
Medication refill / ______
Blood sugar check / ______
Blood pressure check / ______
Vaccination / ______
Wound care / ______
OTHER REASON FOR VISIT, not listed above / ______