Fillable Long-Term Care Facility Influenza Outbreak Report Form (State of Alaska)

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Long-Term Care Facility Influenza Outbreak Report Form (State of Alaska)

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Page 1 of 2 Version 1/5/17
Section of Epidemiology
3601 C Street, Suite 540
Anchorage, AK 99503
Webpage: http://dhss.alaska.gov/dph/Epi/id/Pages/default.aspx
Long-Term Care Facility Influenza Outbreak Report Form
Submit this report when an influenza outbreak is suspected or confirmed in your long term care (LTC) facility. Send to Alaska Section of
Epidemiology Influenza Surveillance Coordinator by fax (907)563-7868.
The definition of an outbreak is: one laboratory-confirmed influenza positive case or ≥2 suspect cases with influenza-like illness among
residents within 72 hours of each other. See Resources for Long-Term Care Facilities for Guidance on Management of Outbreaks http://
dhss.alaska.gov/dph/Epi/id/Pages/influenza/fluinfo.aspx
If you have any questions regarding the control of influenza in your facility please call the Section of Epidemiology at (907) 269-8000.
Additional information is available at: https://www.cdc.gov/flu/professionals/index.htm
Facility Information
Facility Name:
City:
Report Date:
Reporter Information
Name of Reporter:
Contact Phone:
Email address:
Fax:
Nursing Facility Data
Skilled Nursing Facility: Yes No
Number of staff:
Onset date of first case(s):
Number of residents in facility:
Number of residents with influenza-like illness:
Number of residents tested for influenza:
Precautions implemented (droplet precautions, isolations, prophylaxis, etc):
Antivirals and Vaccination
Treatment with antivirals: Yes No
Prophylaxis with antivirals: Yes No
Antiviral type:
Estimated influenza vaccination rates of residents and staff: Residents: Staff:
Influenza-Related Public Health Reporting and Deaths
Any residents laboratory-confirmed with influenza? Yes No
If yes, fill out an Infectious Disease Report Form (http://dhss.alaska.gov/dph/Epi/Documents/pubs/conditions/frmInfect.pdf)
and fax to (907) 561-4239
Any residents with an influenza-associated death? Yes No
If yes, fill out an Influenza-Associated Mortality Case Report Form
(http://dhss.alaska.gov/dph/Epi/Documents/pubs/conditions/frmFluDeath.pdf) and fax to (907) 563-7868 for each resident that
has died
Page 2 of 2 Version 1/5/17
Facility Name:
City:
Date:
Detailed list of residents and employees with influenza-like illness. Employees are designated with an asterisk symbol (*) by their name.
Name: Last, First, M.I.
Age
Unit or Wing
ILI onset
date
Influenza test
performed
(Y/N)
Specimen
collection
date
Lab test
result
Flu
vaccination
date
Hospitalized
(Y/N)
Died (Y/N)
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Long-Term Care Facility Influenza Outbreak Report Form (State of Alaska)

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Completed 11 February 2021

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