Appendix 1: RESPIRATORY LINE LIST Name of school or daycare center: Staff contact: Facility type: Date: Outbreak number assigned by LHD: Total no. of students: Total no. of staff: Please collect the following information for the first 10 students and staff who are out sick with flu-like symptoms. Once complete, cross out the names or identifiers from the line list and submit to the LHD. On the other side of this form, continue to keep a tally of new onset of illness, each day, until the outbreak ends. flu F for results 100 stool or date number Lab > throat Confirmed visit Name Grade Onset Other Diarrhea Hospitalized Notes Age Room Vomiting Bloody Rash Vaccinated Cough Pneumonia Student Staff Fever Sore ED Lab Identifier 1 2 3 4 5 6 7 8 9 10
Appendix 1: RESPIRATORY LINE LIST Name of school or daycare center: Staff contact: Facility type: Date: Outbreak number assigned by LHD: Total no. of students: Total no. of staff: Please collect the following information for the first 10 students and staff who are out sick with flu-like symptoms. Once complete, cross out the names or identifiers from the line list and submit to the LHD. On the other side of this form, continue to keep a tally of new onset of illness, each day, until the outbreak ends. Name or Identifier Age Student Staff Grade Onset date Room number Fever > 100 F Cough Sore throat Pneumonia Vomiting Diarrhea Bloody stool Rash ED visit Hospitalized Vaccinated for flu Lab Confirmed Other Lab results Notes 1 2 3 4 5 6 7 8 9 10
flu-outbreak-toolkit-for-schools.docx