Potential Outbreak - Initial Information

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/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9]|800|811)$?)\s*(?:[.-]\s*)?([2-9]1[02-9]|[2-9][02-9]1|[2-9][02-9]{2})\s*(?:[.-]\s*)?([0-9]{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^\d{3}-\d\d-\d{4}$/

/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/^[0-9]{4,9}$/

/^\d{5}(-\d{4})?$/

f7oxUVrPoWBmshfXvgMPMfxDvAYbaqwM6CP7U27qbwjuM3Ckvb3iBPzwJJTjajtJSBNb3eBuhVzKLmVQukceJ

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Type of Person Completing Report

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Name of Person Completing Report

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Reporter Name and Title

Type of Facility

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If 'other' facility type, please specify

Name of Facility

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County of Facility

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District of Facility

NOTE: Don't know which District to select, click here to find out.

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.).

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Date & Time of Initial Report

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M-D-Y H:M

Primary Class of Symptoms

NOTE: If there are multiple classes of symptoms (e.g., gastrointestinal and dermatological, etc.), please enter each separately.

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Influenza Activity in the District of the Facility

Check the map: https://dph1.adph.state.al.us/influenza/maps/

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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.

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(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?

How many people are in the unit with the greatest number of ill?

(Calculated) Percent Absent in Unit

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Date of First Illness

M-D-Y

Date of Most Recent Illness

M-D-Y

(Calculated) Number of days between first and most recent illness

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Classification of Ill

Patron(s)

Staff

Student(s)/Attendee(s)

Resident(s)/Patient(s)

Other

Unknown

If other, please specify

Symptoms

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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

If other symptom(s), please specify

If fever, highest measured temperature (°F)

Has any laboratory testing already been performed?

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If yes, what type and what were the results?

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Are any ill willing to submit specimens?

Please indicate if any of the ill have:

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Visited an Emergency Department

Been Hospitalized

Died

Not applicable

Number Hospitalized

Number who have visited an Emergency Department

Number who have died

Please submit influenza-associated deaths using the online REPORT card.

Was this associated with an event (e.g., catered event, wedding, graduation party, etc.)?

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Yes

Don't Know

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If yes, date/time of event:

Y-M-D H:M

If restaurant-associated, did all of the patrons dine together (i.e., same group, same table)?

ALNBS Investigation IDs, if applicable

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Type of ALNBS Disease Investigation

Have any control measures been given?

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If yes, date control measures given:

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M-D-Y

Before moving on, please take the time to review the following control measures:

Prevention and Control Measures: Influenza or Influenza-like Illness in Schools or Child Care Facilities

Before moving on, please take the time to review the following control measures:

Prevention and Control Measures: Influenza and Influenza-like Illness in Long-term Care Facilities

Have the control measures provided in the link above been reviewed?

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Did the facility implement scabies sanitation procedures?

Yes

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General Comments

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Upload any pertinent documents:

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Has this outbreak report been reviewed by Central Office?

Yes

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Initials of Person Who Reviewed the Report

Date/Time Reviewed

M-D-Y H:M

Time from Initial Report to Review (in hours)

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Report Follow-up

Justification for report follow-up selection:

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Assigned Outbreak Code

(Calculated) Year of Report

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(Calculated) Total Number of Months

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(Calculated) Month of Report

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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	______

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