Infection Prevention Manual

State of California—Health and Human Services Agency California Department of Public Health Infectious Diseases Branch 850 Marina Bay Parkway Richmond, CA Fax: (510) 620-3425 CDPH 9060 (5/09) PRELIMINARY REPORT OF COMMUNICABLE DISEASE OUTBREAK* Fax to IDB at 510-620-3425 or Email to CDOUTBREAK@cdph.ca.gov REPORTING LOCAL HEALTH DEPARTMENT Reporter Name Local Health Jurisdiction Telephone Number of Reporter Date Reported to LHJ City/Town Where Outbreak Located Local Outbreak Number, if available Is assistance needed? No Yes If Yes, please check: Lab Epi Infection Control Other OUTBREAK PRELIMINARY INFORMATION TO DATE Outbreak syndrome (may check more than one) Respiratory Gastrointestinal Fever Rash Skin/soft tissue infections Bacteremia STD Hepatitis Meningitis/Encephalitis Neurological Unknown Other (list): Major signs and symptoms: Pathogen (suspected or confirmed; do not report lice, scabies, or varicella): Indicate whether the pathogen is: Suspected Laboratory-Confirmed Unknown Number Ill Number Lab Confirmed Number Hospitalized Number Died First Onset Date Latest Onset Date Thus Far If institutional setting Number of s taff ill Number of residents ill Suspected Mode of Transmission Foodborne Waterborne Airborne Person to person Unknown Other (list): Suspect Source or Vehicle (e.g. food item, event, or index case) OR Unknown SETTING INFORMATION Setting Type (check all settings where illnesses occurred) Restaurant Acute care hospital Child day care/pre-school Jail Catered Party Surgical center Primary school (K-5) Prison Hotel Urgent care center/Clinic Middle/High school (6-12) Military facility Private home Skilled nursing facility College/University Shelter Wedding Residential care facility Camp General community Adult day care Other (describe): Name(s) of facility/school/setting: PUBLIC HEALTH ACTIONS TAKEN OR PLANNED Notification of public Notification of medical community Case finding Contact tracing Human specimen collection and testing Environmental inspection/investigation Infection control measures Other measures (list): ADDITIONAL INFORMATION (add extra page if needed) Other jurisdictions affected (list): *Outbreak is defined as a larger than expected number of cases likely due to a common source. Your Agency Name (PN System)