MISSOURI OUTBREAK SURVEILLANCE FORM

ID:OUTBREAK NAME:

REPORT DATE:

REPORTED BY: (circle 2-digit code)

01Local Health Department / 05Nursing Home/Long Term Care / 09Private Physician/Health Care Provider

02District Office

/ 06Child Care / 10Private Citizen
03Hospital(including laboratory) / 07School/College / 11Other State Agency
04Laboratory (non-hospital lab) / 08Industry Worksite / 12Other, specify ______

DATE OF REPORT TO LOCAL HEALTH AGENCY:

EVENT DESCRIPTION: (circle 2-digit code)

01Outbreak or possible outbreak /

04Cluster of Events

/ 07Other, specify ______
02Case Report / 05Sensitive Event
03Toxic Exposure / 06Artifact (false alarm)

CRITICAL EVENT DATE:

Number of persons reported ill:Attack Rate: ______

Number of persons hospitalized:

Number of reported deaths:

Estimated number of persons exposed/at risk:

SUSPECTED LOCATION OF EXPOSURE:

In State Out of State Out of Country

County: ______State: ______Country: ______

GENERAL CATEGORY: (circle 2-digit code)

01Infectious Disease / 05Environmental Hazard (noninfectious)
02Special Syndrome (Reye, Kawasaki, GBS) / 06Occupational Hazard (noninfectious)
03Injury/Trauma / 08Other, specify:______
04Chronic Disease /

09Unknown

SUSPECT MODE OF TRANSMISSION: (circle 2-digit code)

01Food / 04Air / 07Environmental Exposure
02Water /

05Person-to-Person

/ 08Worksite Exposure
03Vector / 06Medical Procedure/Medication / 09Other, specify: ______

What is the specific suspect vehicle (product) or vector? ______

______

EXPOSURE SETTING/POPULATION AT RISK: (circle 2-digit code)

01Camp / 09Immigrant/Alien / 18Institution/Prison
02Childcare / 10Military Base/Camp / 19Healthcare Facility/Hospital/
03Church/Temple / 12Occupational/Workplace / Clinic/Medical Care Site/
04Club/Health Spa /

14Resort/Hotel

/ Nursing/Long Term Care
05Disaster (natural or man-made) / 15Restaurant/Food Service / 88Other, specify
06General Community / 16School/College / 99Unknown
07Home/Private Gathering / 17Catered Event

SPECIFIC CAUSE: (circle 3-digit code)

151AGI* / 048Hepatitis, NANB / 103Reye Syndrome
056AIDS / 012Hepatitis (unspecified) / 105Rheumatic Fever
104Amebiasis / 106Influenza / 025Rocky Mountain Spotted Fever
217ARI** / 049Legionellosis / 020Rubella
001Aseptic Meningitis / 038Hansen Disease (Leprosy) / 100Salmonella, serotype: ______
152Bacillus cereus / 039Leptospirosis / 225Scabies
053Botulism, foodborne / 158Listeriosis / 160Scombrotoxin
002Brucellosis / 108Lyme disease / 101Shigellosis
102Campylobacteriosis / 013Malaria / 200Silicosis
003Chickenpox (Varicella) / 050Measles (indigenous) / 161S. Aureus
153Ciguatoxin / 051Measles (imported) / 219S. Aureus - MRSA***
154C. perfringens / 016Meningococcal infection / 162Strep group A
155Cryptosporidiosis / 018Mumps / 032Syphilis
004Diphtheria / 555Norovirus-like / 021Tetanus
156E. coli O157:H7 / 556Norovirus (laboratory confirmed) / 052Toxic Shock Syndrome
005Encephalitis, primary / 019Pertussis / 027Trichinosis
218Fifth Disease / 044Plague / 022Tuberculosis
157Giardiasis / 041Polio, (paralytic) / 023Tularemia
029Gonorrhea / 045Psittacosis / 024Typhoid Fever
011Hepatitis A / 159Pseudomonas / 026Typhus (murine)
010Hepatitis B / 034Rabies (animal) / 047V. cholerae - 01
046Rabies (human) / 226V. cholerae non-01
777Environmental hazard or toxin: specify ______/ 163V. parahaemolyticus
888Other, specify ______/ 999Unknown

*Acute Gastrointestinal Illness of unknown etiology

**Acute Respiratory Illness of unknown etiology

***Methicillin-resistant Staphylococcus aureus (MRSA)

LEVEL OF INVESTIGATION BY LOCAL AGENCY:

01Received report / 05Primary responsibility for investigation
02Handled by other person/office/agency / Responsible agency: ______
03Consultation provided by phone or mail / 06Referred to District Office
04Onsite visit or assistance / 07Assessment Completed: No further action deemed necessary

SHADED AREAS TO BE COMPLETED BY DISTRICT OFFICE

LEVEL OF INVESTIGATIONDISTRICT:______

01Received report / 03Consultation provided by phone or mail / 05Primary responsibility for investigation
02Handled by other person/office/agency / 04Onsite visit or assistance / 06Other: ______

STATUS OF REPORT: Check one: Provisional Administratively Closed Final

Comments: ______

Form completed by: ______Date: ______

Revised 12/2010CD-51