FORM COMPLETED BY: FACILITY AREA(S): DATE: DATE OUTBREAK DECLARED: DATE OUTBREAK DECLARED OVER: New or Fever Sore Joint Extreme Other Date Date Result Date of Date Date of Date of Resident Worse Throat Pain or Fatigue Nose Symptom First Swab Flu A, B Last Flu Antiviral Recovery Resident Date of Cough Muscle Onset of Test RSV etc. Vaccine Started Hospital Death Y/N Name of Resident Ache Symptom Taken Admission Date of Y/N Y/N Y/N Specify DD/MM Sex birth Y/N or put MM/YY DD/MM DD/MM (Surname, Initial) Y/N NONE DD/MM for no other Sx
FORM COMPLETED BY: FACILITY AREA(S): DATE: DATE OUTBREAK DECLARED: DATE OUTBREAK DECLARED OVER: Name of Resident (Surname, Initial) Sex Date of birth New or Worse Cough Y/N Fever Y/N Sore Throat Y/N Joint Pain or Muscle Ache Y/N Extreme Fatigue Y/N Nose Y/N Other Symptom Specify or put NONE for no other Sx Date First Onset of Symptom Date Swab Test Taken Result Flu A, B RSV etc. Date of Last Flu Vaccine MM/YY Date Antiviral Started DD/MM Date of Recovery DD/MM Date of Resident Hospital Admission DD/MM Resident Date of Death DD/MM
wRCF_Guidelines.docx