Type of Person Completing Report
* must provide value
Health Department Personnel Non-Health Department Personnel
Name of Person Completing Report
* must provide value
Type of Facility
* must provide value
Skilled Nursing or Assisted Living Facility Hospital School/Daycare Prison Recreational Water Facility Recreational, non-water Hotel College or University Restaurant Other N/A - identified through routine surveillance
Examples of Skilled Nursing Facilities include nursing home, rehabilitation center, etc.
If 'other' facility type, please specify
Name of Facility
* must provide value
Do NOT use the symbol & in this field. Please use the word and instead.
County of Facility
* must provide value
Autauga County Baldwin County Barbour County Bibb County Blount County Bullock County Butler County Calhoun County Chambers County Cherokee County Chilton County Choctaw County Clarke County Clay County Cleburne County Coffee County Colbert County Conecuh County Coosa County Covington County Crenshaw County Cullman County Dale County Dallas County DeKalb County Elmore County Escambia County Etowah County Fayette County Franklin County Geneva County Greene County Hale County Henry County Houston County Jackson County Jefferson County Lamar County Lauderdale County Lawrence County Lee County Limestone County Lowndes County Macon County Madison County Marengo County Marion County Marshall County Mobile County Monroe County Montgomery County Morgan County Perry County Pickens County Pike County Randolph County Russell County Saint Clair County Shelby County Sumter County Talladega County Tallapoosa County Tuscaloosa County Walker County Washington County Wilcox County Winston County Out of State
District of Facility
NOTE: Don't know which District to select, click
here to find out.
Northern Northeastern West Central Jefferson East Central Southwestern Southeastern Mobile Unknown
Estimated number of people in the facility
NOTE: This is not just the people ill. We want to know ultimately how many people were potentially exposed. Inclusive of all people in facility, regardless of classification (staff/residents/patrons/patients, etc.).
* must provide value
If unknown, leave blank, complete form, and click 'Save and Return Later'.
Date & Time of Initial Report
* must provide value
Now M-D-Y H:M If non-ADPH personnel, click 'Now'
Primary Class of Symptoms
NOTE: If there are multiple classes of symptoms (e.g., gastrointestinal and dermatological, etc.), please enter each separately.
* must provide value
Gastrointestinal Influenza-like Illness/Influenza COVID-19 Other Respiratory Dermatological Unknown
Examples: Gastrointestinal (vomiting, diarrhea); Influenza-like illness/Influenza (cough, fever, sore throat); Dermatological (rash, itching); Unknown (symptom class is unclear, e.g., dizziness and myalgia)
Influenza Activity in the District of the Facility
* must provide value
Districts with Significant Influenza Activity Detected (dark blue) Districts with Lab-confirmed Case(s) Within Last 3 Weeks (light blue) Districts with No Significant Influenza Reported (white)
On Date of Most Recent Illness
REMINDER: If the influenza activity in the district is either white or light blue and the facility type is skilled nursing/assisted living, specimens should be requested.
Use the following investigation code to submit specimens to BCL: INF-______
Use the following investigation code to submit specimens to BCL: COV-______
Approximate Number of Ill
NOTE: This is NOT the number absent. This is the number ill with the primary class of symptoms selected above.
* must provide value
If unknown, leave blank, complete form, and click 'Save and Return Later'.
(Calculated) Percent Absent in Facility
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If separate units (classrooms, nursing home halls, etc.) what is the greatest number ill in a single unit?
If unknown, leave blank, complete form, and click 'Save and Return Later'.
How many people are in the unit with the greatest number of ill?
If unknown, leave blank, complete form, and click 'Save and Return Later'.
(Calculated) Percent Absent in Unit
View equation
Today M-D-Y
Date of Most Recent Illness
Today M-D-Y
(Calculated) Number of days between first and most recent illness
View equation
Patron(s)
Staff
Student(s)/Attendee(s)
Resident(s)/Patient(s)
Other
Unknown
Select all that apply
Symptoms
* must provide value
Abdominal pain
Chills
Congestion
Cough
Diarrhea
Diarrhea, Bloody
Diarrhea, Watery
Discolored urine
Fever (measured or subjective)
Headache
Itching
Jaundice
Lethargy or tiredness
Myalgia or muscle aches
Nausea
New loss of smell or taste
Pneumonia
Rash
Runny nose (rhinorrhea)
Shortness of Breath
Sore throat
Vomiting
Other
No symptom information provided
Select all that apply
If other symptom(s), please specify
If fever, highest measured temperature (°F)
If unknown, leave blank, complete form, and click 'Save and Submit'.
Has any laboratory testing already been performed?
* must provide value
Yes No Unknown
If yes, what type and what were the results?
* must provide value
Are any ill willing to submit specimens?
Yes No Unknown
Please indicate if any of the ill have:
* must provide value
Visited an Emergency Department
Been Hospitalized
Died
Not applicable
Select all that apply
If unknown, leave blank, complete form, and click 'Save and Submit'.
Number who have visited an Emergency Department
If unknown, leave blank, complete form, and click 'Save and Submit'.
If unknown, leave blank, complete form, and click 'Save and Submit'.
Please submit influenza-associated deaths using the online
REPORT card .
Was this associated with an event (e.g., catered event, wedding, graduation party, etc.)?
* must provide value
Yes
No
Don't Know
If yes , date/time of event:
Now Y-M-D H:M
If restaurant-associated, did all of the patrons dine together (i.e., same group, same table)?
Yes No Unknown
ALNBS Investigation IDs, if applicable
Separate multiple IDs with a comma
Type of ALNBS Disease Investigation
Have any control measures been given?
* must provide value
Yes No
If yes , date control measures given:
* must provide value
Today M-D-Y MM-DD-YYYY
Before moving on, please take the time to review the following control measures:
Before moving on, please take the time to review the following control measures:
Have the control measures provided in the link above been reviewed?
* must provide value
Yes No
Did the facility implement scabies sanitation procedures?
Yes
No
Upload any pertinent documents:
Has this outbreak report been reviewed by Central Office?
Yes
No
Initials of Person Who Reviewed the Report
Now M-D-Y H:M
Time from Initial Report to Review (in hours)
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Warrants further investigation Although meets criteria for an outbreak, this report does not warrant further investigation Does not meet criteria for outbreak/cluster investigation, including single illnesses Although multiple persons ill, only control measures should be provided (e.g., school/daycare, skilled nursing/assisted living) Needs more information Needed information was not provided within 7 days of request Merged with another investigation
Justification for report follow-up selection:
(Calculated) Year of Report
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(Calculated) Total Number of Months
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(Calculated) Month of Report
View equation
If you would like to print this outbreak summary, highlight the information below, then click
Ctrl plus
P on your keyboard.
Outbreak Summary
Date of Report ______ | Submitted by: ______ Symptom Classification ______ Facility Information ______ | ______ - ______ Illness Information Number Ill: ______ | Earliest Illness Onset: ______ | Most Recent Illness Onset: ______ Lab Testing Any Performed?: ______ | If yes, results: ______
Report Follow-up ______ | Reviewed on ______ by ______ Follow-up Justification ______