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