MEDICAL EVENT REPORT ELEMENTS FOR DISEASE OUTBREAK/CLUSTER REPORTS 1. Date of a. Date of case: b. Date of onset of last case: 2. Reporting command: 3. Name of reporter: 4. Reporter's telephone number (include commercial and DSN, as applicable): 5. Reporter's e-mail address: 6. Reporting command's unit identification code (UIC): 7. Diagnosis/Etiologic Agent: 8. Diagnosis/outbreak status (suspected, probable or lab confirmed): 9. Type of outbreak: foodborne, waterborne, vector-borne GI-infectious, respiratory, dermatologic, neurologic, or unknown/other. 10. Number of people affected: a. Number of cases lab confirmed: b. Number of probable/suspect cases: 11. Affected population's geographic location: a. City: b. State: c. Country: 12. Narrative: a. Case definition (include specific patient criteria or epidemiological criteria used: b. If the RME status is "lab confirmed," describe the test(s) and sample(s) tested to include the sample(s) specific types and source(s): c. Investigation description. Describe epidemiologic studies (patient exposure histories/surveys, food/water exposure history attack rate comparisons, travel histories, etc.) and environmental evaluations of, for example, food and water production, used to identify a common source or important risk factors. Include lists of specific questions used in surveys/questionnaires: d. List specific preventive measures taken (i.e. prophylaxis,immunization, patient cohorting, isolation, quarantine, hand washing protocols, food service protocols, environmental cleaning, space closures, work limitations, pesticide applications, etc.):
MEDICAL EVENT REPORT ELEMENTS FOR DISEASE OUTBREAK/CLUSTER REPORTS 1. Date of a. Date of case: b. Date of onset of last case: 2. Reporting command: 3. Name of reporter: 4. Reporter's telephone number (include commercial and DSN, as applicable): 5. Reporter's e-mail address: 6. Reporting command's unit identification code (UIC): 7. Diagnosis/Etiologic Agent: 8. Diagnosis/outbreak status (suspected, probable or lab confirmed): 9. Type of outbreak: foodborne, waterborne, vector-borne GI-infectious, respiratory, dermatologic, neurologic, or unknown/other. 10. Number of people affected: a. Number of cases lab confirmed: b. Number of probable/suspect cases: 11. Affected population's geographic location: a. City: b. State: c. Country: 12. Narrative: a. Case definition (include specific patient criteria or epidemiological criteria used: b. If the RME status is "lab confirmed," describe the test(s) and sample(s) tested to include the sample(s) specific types and source(s): c. Investigation description. Describe epidemiologic studies (patient exposure histories/surveys, food/water exposure history attack rate comparisons, travel histories, etc.) and environmental evaluations of, for example, food and water production, used to identify a common source or important risk factors. Include lists of specific questions used in surveys/questionnaires: d. List specific preventive measures taken (i.e. prophylaxis,immunization, patient cohorting, isolation, quarantine, hand washing protocols, food service protocols, environmental cleaning, space closures, work limitations, pesticide applications, etc.):