Line Listing of Residents - Respiratory Outbreak or Increased Incidence of ILI Symptoms (For Resident/Patient Cases) Facility Case Laboratory Symptoms Category Unit/Floor Patient's Date unit Date Room Flu to sample Confirmed, (dd-mmm- Lab Date Last Name First Name Number Vaccine submitted Probable, Pain Nose Joints Date yyyy) MRN Age Sex sample (dd-mmm- Comments Throat or Not a (when past 12 Died another SOB M/F submitted yyyy) Fever Cough Hospitalized Case symptoms months Headache Hospitalized Congestion Muscle Sore Runny Painful yyyy) began) Transferred yyyy)
Line Listing of Residents - Respiratory Outbreak or Increased Incidence of ILI Symptoms (For Resident/Patient Cases) Facility Laboratory Case Category Symptoms Unit/Floor Date (dd-mmm- yyyy) Last Name First Name MRN Age Sex M/F Patient's Room Number (when symptoms began) Flu Vaccine past 12 months Lab sample submitted Date sample submitted yyyy) Confirmed, Probable, or Not a Case Date (dd-mmm- yyyy) Fever Cough Sore Throat Painful Joints Muscle Pain Runny Nose Headache SOB Congestion Date yyyy) Hospitalized Transferred to another unit Hospitalized Died Comments