Submitter Information Provide your name and affiliation in the fields below in the event ADPH Infectious Diseases & Outbreaks Division staff need to clarify details in your submission.
Name of Submitter:
Type of Submitter:
Reporter Information Provide the name of the person who initially reported the potential outbreak to ADPH. The reporter may receive a follow-up phone call or e-mail from ADPH Infectious Diseases & Outbreaks Division staff to gather additional details and/or provide control measures.
Name/Title of Reporter:
Date/Time of Initial Report:
Phone Number:
E-mail Address:
Facility/Setting Information Tell us a little bit about the facility/setting experiencing the potential outbreak. Please include information about the type and name of the facility, as well as where it is located.
Type of Facility/Setting:
Name of Facility/Setting:
NOTE: Do NOT use the symbol "&" in this field; use the word "and" instead.
County of Facility: District of Facility:
Clinical Information About the Potential Outbreak Provide more information about the symptomology, illness frequency, and severity among persons involved, as well as describe any testing that has already been performed for this potential outbreak.
Signs and Symptoms Details Primary Class:
NOTE: If there are multiple classes of signs/symptoms (e.g., gastrointestinal and dermatological, etc.), please enter each in a separate submission.
EXAMPLES:
Dermatological (itching, rash)
Gastrointestinal (diarrhea, vomiting)
Respiratory: COVID-19-like illness/COVID-19 (chills, congestion, cough, fatigue, fever, shortness of breath, new loss of taste or smell), Influenza-like illness/Influenza (cough, fever, sore throat), Legionella (cough, fever, headaches, muscle aches, shortness of breath, pneumonia)
Other (urinary tract infections, bloodstream infections, wound infections, asymptomatic colonization detected, etc.) Unknown (symptom class is unclear, e.g.,dizziness and myalgia)
Signs and Symptoms:
Illness Frequency and Severity Details Approximate Number of Persons Ill:
NOTE: Leave blank if unknown.
Are multiple units (e.g., classrooms, pods, halls, wings, etc.) impacted?
Date of First Illness:
Date of Most Recent Illness:
Indicate if any (and how many) of the ill have:
In-House or Laboratory Testing Information Has any testing already been performed?
If yes , what type of testing was performed?
If yes , what were the results?
Are any ill persons willing to submit specimens?
Additional Information About the Potential Outbreak We have just a few more questions to ask about this potential outbreak. If you are a non-health department employee, please take the time to review the control measures provided. Finally, provide additional comments and/or upload any documents you believe are relevant to the outbreak.
Event/Facility Specific Information Was this associated with an event (e.g., catered event, wedding, graduation party, etc.)?
If yes , date/time of event:
If restaurant-associated , did all of the patrons dine together (i.e., same group, same table)?
Control Measures Additional Comments & Document Upload General Comments:
Upload any pertinent documents:
Type of Person Completing Report
* must provide value
Health Department Personnel Non-Health Department Personnel
Name of Person Completing Report
* must provide value
Reporter's Phone Number
* must provide value
Reporter's E-mail
* must provide value
Type of Facility
* must provide value
Skilled Nursing or Assisted Living Facility
Skilled Nursing Facility
Assisted Living Facility
Hospital
School/Daycare
Prison
Recreational Water Facility
Recreational, non-water
Hotel
College or University
Restaurant
Other (please specify)
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
**RETIRED** 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
View equation
**RETIRED** Estimated number of people in the facility
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
Dermatological
Gastrointestinal
Respiratory - COVID-19-like Illness/COVID-19
Respiratory - Influenza-like Illness/Influenza
Respiratory - Legionella
Respiratory - Other
Other (specify)
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)
Other, specify
* must provide value
**RETIRED** Influenza Activity in the District of the Facility
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: Since influenza or influenza-like illness is suspected and the facility type is skilled nursing/assisted living, hospital, or prison, specimens will be requested by ADPH if less than 5 days of last known ill. Three - five specimens should be submitted for persons who were not previously tested and have symptoms consistent with influenza or influenza-like illness. However, specimens can (or should) also be submitted for symptomatic persons who have tested negative during the facility's initial screening.
(For ADPH Use Only) Use the following investigation code to submit specimens to BCL: INF-______
PLEASE REVIEW: Before selecting COVID-19 or COVID-19-like illness, please confirm that the potential outbreak being reported meets one of the following criteria.
Acute Care Hospitals and Critical Access Hospitals :
≥2 cases of probable* or confirmed COVID-19 among patients 4 or more days after admission for a non-COVID condition, with epi-linkage¶ OR ≥2 cases of suspect† , probable* , or confirmed COVID-19 among healthcare personnel†† AND ≥1 case of probable* or confirmed COVID-19 among patients 4 or more days after admission for a non-COVID condition, with epi-linkage§,¶ Long-Term Care Facilities (LTCF) and Long-Term Acute Care Hospitals:
≥2 cases of probable* or confirmed COVID-19 among residents, with epi-linkage¶ OR ≥2 cases of suspect† , probable* , or confirmed COVID-19 among healthcare personnel†† , with epi-linkage§,¶ AND no other more likely sources of exposure for at least 1 of the cases Definitions for the superscripts can be found on page 3 of CORHA's "Proposed Investigation/Reporting Thresholds and Outbreak Definitions for COVID-19 in Healthcare Settings ".
REMINDER: Since COVID-19 or COVID-19-like illness is suspected and the facility type is skilled nursing/assisted living, hospital, or prison, specimens will be requested by ADPH if less than 5 days of last known ill. Three - five specimens should be submitted for persons who were not previously tested and have symptoms consistent with COVID-19 or COVID-19-like illness. However, specimens can (or should) also be submitted for symptomatic persons who have tested negative during the facility's initial screening.
(For ADPH Use Only) Use the following investigation code to submit specimens to BCL: COV-______
Have any of the ill persons left the facility/setting in the 14 days before illness onset?
If Respiratory - Legionella , have any of the ill persons left the facility/setting in the 14 days before illness onset?
* must provide value
Yes No Unknown
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'.
**RETIRED** (Calculated) Percent Absent in Facility
View equation **RETIRED** 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'.
**RETIRED** 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'.
**RETIRED** (Calculated) Percent Absent in Unit
View equation Are multiple units (e.g., classrooms, pods, halls, wings, etc.) impacted?
Yes No Unknown
Today M-D-Y
Date of Most Recent Illness
Today M-D-Y
**RETIRED** (Calculated) Number of days between first and most recent illness
View equation **RETIRED** Classification of Ill
Select all that apply
**RETIRED** If other, please specify
Symptoms
* must provide value
Select all that apply
If other symptom(s), please specify
**RETIRED** 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 of testing was performed?
* must provide value
Antibody/IgG/IgM
Antigen/EIA/Rapid Cartridge
Molecular/NAAT/PCR
Culture
Other (please specify)
Unknown
Refer to lab result or package insert for the test kit.
If Other, please specify:
* must provide value
Refer to lab result or package insert for the test kit.
If yes, 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
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'.
NOTE: 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
Provide the type of ALNBS Disease Investigation:
Please list the ALNBS Investigation IDs:NOTE: Separate multiple IDs with a comma.
Type of ALNBS Disease Investigation
ALNBS Investigation IDs, if applicable
Separate multiple IDs with a comma
Have any control measures been given?
If yes , date control measures given:
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:
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:
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:
Before moving on, please take the time to review the appropriate control measures:
Have the control measures provided in the link above been reviewed?
Have the control measures provided in the link above been reviewed?
* must provide value
Yes
No
Did the facility implement scabies sanitation procedures?
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)
View equation 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) LTCF COVID-19 Outbreak Response: Regional IP will provide control measures and offer ICAR consultation Non-LTCF COVID-19 Outbreak: No further investigation warranted Influenza outbreak in institutional settings (e.g., skilled nursing/assisted living, hospital, prison): control measures should be provided, and specimens requested if less than 5 days of last known ill Influenza outbreak in non-institutional settings and schools/daycares: only control measures should be provided Scabies outbreak in institutional settings (e.g., skilled nursing/assisted living, hospital, prison): control measures should be provided, and continue to monitor for two months Scabies outbreak in non-institutional settings and schools/daycares: control measures should be provided, and continue to monitor for two months Needs more information Needed information was not provided within 7 days of request Merged with another investigation
Justification for report follow-up selection:NOTE: Include the investigation code to submit specimens to the BCL for ILI/Influenza and CLI/COVID-19 outbreaks, in addition to the return code in the justification.
(Calculated) Year of Report
View equation (Calculated) Total Number of Months
View equation (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: ______ Report Follow-up ______ | Reviewed on ______ by ______ Follow-up Justification ______ Link to Return to Survey https://epiweb.adph.state.al.us/redcap/surveys/?s=CT7YLLEFMP&__return=1
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