OUTBREAK NUMBER: 2247-- / Facility Contact Name: / Total Number / Date of Index Case:
/ Date Notified: / Date Declared Over:
Facility: / Tel: / # Staff: / # Residents/
Patients:
Ward/
Room #/ Occupation / Name
(Last name, First name)
Print name out in full / / For Residents Enter
Date of Birth
yyyy/mm/dd
For Staff Enter
Last day worked
yyyy/mm/dd / Date of Onset
yyyy/mm/dd / Vaccine Date
yyyy/mm/dd / Specimen / Daily Progress
Month: Year:
Date
yyyy/mm/dd / Results / dd / dd / dd / dd / dd / dd / dd / dd / dd / dd / dd / dd / dd / dd
FOR HEALTH UNIT USE ONLY -Initials/Designation
General enteric case definition: 2 or more episodes of vomiting and/or diarrhea in 24 hours. / General respiratory case definition: 2 or more new symptoms of respiratory illness. / COMMENTS:
Check all that apply. / Check all that apply.
D - Diarrhea / F - Fever/abnormal
temperature / F - Fever/abnormal
temperature / ST - Sore throat/ hoarseness
V – Vomiting / Dc - Dry Cough
N - Nausea / SF - Symptom Free / H - Headache / Pc - Productive Cough
C - Abdominal cramps / RC - Recovered / T - Tiredness / LS - Abnormal lung sounds
(ex// crackles/rales, wheezes)
H - Headache / Hos - Hospitalization / Nd - Nasal discharge/
congestion / Pne - Pneumonia [CXR+]
T - Tiredness / Dec - Deceased / SF - Symptom Free
M - Muscle Aches / Hos - Hospitalization
RC - Recovered / Dec - Deceased
The information being collected on this form is collected under the authority of the Health Protection and Promotion Act R.S.O. 1990, C.H.7, s.5 for the purpose of preventing the spread of communicable disease and to provide statistical data to the Ministry of Health and
Long-Term Care. Questions regarding the collection and use of personal health information should be directed to the Privacy Officer of the North Bay Parry Sound District Health Unit, 681 Commercial Street, North Bay, Ontario, P1B 4E7, Phone:(705) 474-1400.