New Jersey Department of Health

Communicable Disease Service

OUTBREAK REPORT FOR CHILD CARE, SCHOOL AND CAMP SETTINGS

Name of Lead Public Health Agency

County

E#

Date Outbreak Reported to Local Health Department (LHD):

Date Reported to State Health Department

BRIEF SUMMARY
Summary should include key facts that describe what happened. Some information to include: date and place of outbreak, key statistics (number exposed, number of cases, number hospitalized, number of deaths, average duration of illness), causative or suspect organism, control measures and recommendations.

FACILITY INFORMATION
A. FACILITY DESCRIPTION
Name of Facility

Telephone Number

Street Address

County

City/Town

Zip Code

Name of Contact Person

Contact Telephone Number

Type of Facility/Population (check all that apply):	Total Number of:
Child Care	College/University	Students:
Pre-School	Day Camp	Children:
School/Grade Levels
Residential Camp	Staff:
State the number of buildings, wings, units, cabins, floors, etc. that make up the facility. Include number and describe population per area (e.g., age group, grade, student, staff, etc.).

B. OUTBREAK DEMOGRAPHICS
Students:	Total Number (Census):

# Ill:

# Hospitalized:

# Visited ER:

# Visited HCP:

# Deaths:

Staff: *	Total Number:

# Ill:

# Hospitalized:

# Visited ER:

# Visited HCP:

# Deaths:

* Staff includes volunteers, teachers, counselors, housekeeping, recreational, cafeteria, health and administrative activities.
Gender (estimated percent of the primary cases):	Male:	%	Female:	%
Specify location of outbreak within physical structure described above. If requested, Attach floor plan and identify affected area(s):

Illness Onset Date – FIRST Case

Illness Onset Date – LAST Case

Incubation Period	Duration of Illness (e.g., 24-48 hours, 1-5 days)
Shortest	Minutes Hours Days	Shortest	Minutes Hours Days
Median	Minutes Hours Days	Median	Minutes Hours Days
Longest	Minutes Hours Days	Longest	Minutes Hours Days
Total Number of Cases for Whom Information is Available:

Total Number of Cases for Whom Information is Available:

Unknown Incubation Period	Unknown Duration of Illness
Type of Illness
GI Respiratory/ILI Influenza Rash Illness (specify if known):
Other (specify):
Signs and Symptoms (check all that apply and document % of cases for each):
X	%	Sign or Symptom
X	%	Sign or Symptom
X	%	Sign or Symptom
Abdominal cramps
Fatigue
Nausea
Bloody stool
Fever
Rash
Chills
Headache
Sore throat
Cough
HUS
Vomiting
Diarrhea
Nasal Congestion
Other (Specify):

OUTBREAK INVESTIGATION
A. INVESTIGATION TEAM
Representative’s Position
Name/Title
Telephone Number
Facility
Local Health
NJDOH
Other (Specify)

B. OUTBREAK CASE DEFINITION

C. MODE OF TRANSMISSION
Foodborne Person to Person Waterborne No Source Identified
Other (specify):

D. LABORATORY TESTING
No Specimens Obtained	Number of Specimens Tested

Number of Specimens Tested Positive

Agent(s) Detected:

E. CONSULTATION/INVESTIGATION: TYPE AND FINDINGS
Health Officer: On-site evaluation? No Yes
Name:
Public Health Nurse: On-site evaluation? No Yes
Name:
Registered Environmental Health Specialist: On-site evaluation? No Yes

If Yes, please attach report.
Name:
Other (Specify):

CONTROL MEASURES
Refer to control measures section of outbreak guidance document http://www.nj.gov/health/cd/outbreaks.shtml. Complete and attach section to this report.

DOCUMENTATION
Documents Attached to this Outbreak Summary (check all that apply):
Epidemic Curve	Line-Listing (required)
REHS Facility Inspection Report	Floor Plan
Lab Test Reports (required if available)	Foodborne Outbreak Summary Form
Waterborne Outbreak Summary Form
Control Measures (required)	Other (specify):

OUTCOME
Date Outbreak Resolved (i.e., control measures lifted):

Recommendations for Future Actions

Adhere to Timely Reporting

Revise Protocol

Develop New Protocol

Change Product Use

Reinforce Exclusion	Other (Please describe):

COMPLETED BY
Name:	Title:
Agency:
Phone:	Fax:
Email:

OUTBREAK REPORT FOR CHILD CARE, SCHOOL AND CAMP SETTINGS

(Continued)

CDS-38

AUG 15	Page 4 of 4 Pages.

AUG 15	Page 1 of 4 Pages.

CDS-

ewhite

2015-07-17

njdoh