Appendix 13 Example line lists for Influenza Outbreaks Table A13.1 Staff Illness report example line list – Illness Report and Tracking Form (example) Update daily and email or FAX each weekday to your local public health authority ILLNESS DATE Public Health Notified: FACILITY NAME: TIME Public Health Notified: TELEPHONE: AFTER HOURS CONTACT: EMAIL: FAX: FORM COMPLETED BY: DATE OUTBREAK FACILITY AREA(S): DATE: DATE OUTBREAK DECLARED: DECLARED OVER: Cough, Fever Sore Joint Pain or Extreme Runny Other Symptom Date Onset Date Result Date of Date Date of Date Date Work New or Temp Throat Muscle Ache Fatigue Nose Specify Sx or NONE of first Swab Flu A, Last Flu Antiviral Recovery Last Returned at Date Worse for no Other Sx Symptom Test B Vaccine Started worked to work at other Name of Staff Member Sex of RSV at RC Facility RCF? (Surname, Initial) Y/N Y/N Y/N Y/N Y/N DD/MM birth etc. Y/N DD/MM DD/MM MM/YY DD/MM DD/MM DD/MM Y/N RESIDENT illness report and Tracking Form (example) Update daily and email or FAX each weekday to your local public health authority Table A13.2 Resident Illness report example line list – DATE PUBLIC HEALTH NOTIFIED: FACILITY NAME: RESIDENT illness TIME PUBLIC HEALTH NOTIFIED: TELEPHONE: AFTER HOURS CONTACT: FAX:
Appendix 13 Example line lists for Influenza Outbreaks Table A13.1 Staff Illness report – example line list Illness Report and Tracking Form (example) Update daily and email or FAX each weekday to your local public health authority FACILITY NAME: ILLNESS DATE Public Health Notified: TIME Public Health Notified: TELEPHONE: AFTER HOURS CONTACT: EMAIL: FAX: FORM COMPLETED BY: FACILITY AREA(S): DATE: DATE OUTBREAK DECLARED: DATE OUTBREAK DECLARED OVER: Name of Staff Member (Surname, Initial) Sex Date of birth Cough, New or Worse Y/N Fever Temp Y/N Sore Throat Y/N Joint Pain or Muscle Ache Y/N Extreme Fatigue Y/N Runny Nose Y/N Other Symptom Specify Sx or NONE for no Other Sx Date Onset of first Symptom DD/MM Date Swab Test DD/MM Result Flu A, B RSV etc. Date of Last Flu Vaccine MM/YY Date Antiviral Started DD/MM Date of Recovery DD/MM Date Last worked at RC DD/MM Date Returned to work at Facility DD/MM Work at other RCF? Y/N RESIDENT illness report and Tracking Form (example) Update daily and email or FAX each weekday to your local public health authority Table A13.2 Resident Illness report – example line list FACILITY NAME: RESIDENT illness DATE PUBLIC HEALTH NOTIFIED: TIME PUBLIC HEALTH NOTIFIED: TELEPHONE: AFTER HOURS CONTACT: FAX: