Screening Form - Respiratory Illness In Residents Or Staff

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California Department of Public Health
Viral and Rickettsial Disease Laboratory
RESPIRATORY ILLNESS in RESIDENTS or STAFF
Screening Form
(E.G., PHYSICIANS, NURSES, AIDES, VOLUNTEERS)
Rev 4/2/08
Facility name: ___________________________________________________________________
Facility contact: __________________________________
Address: ___________________________ City: _____________________ Phone: ________________
Type of facility (e.g., Skilled Nursing, Residential Care, etc): ____________________ Number of beds: ______
Date of first case: _____/______/_____ Date of last case: _____/_____/_____
Total number of clinical cases in:
Residents _____
Staff _______
Total number of laboratory -confirmed cases:
Residents _____
Staff _______
1
Number vaccinated for flu ≥14 days prior to illness
?
Residents _____
Staff _______
2
Number of contacts who received antiviral prophylaxis
?
Residents _____
Staff _______
If yes, antiviral used:
Amantadine
Rimantadine
Oseltamivir (Tamiflu)
2
Number of contacts who received antiviral treatment
?
Residents _____
Staff _______
If yes, antiviral used:
Amantadine
Rimantadine
Oseltamivir (Tamiflu)
Number of cases hospitalized due to this outbreak?
Residents _____
Staff _______
Number of cases who died due to this outbreak?
Residents _____
Staff _______
If laboratory-confirmed, list agent identified:________________________________________________ Method of
diagnosis:
Rapid test
Isolation
DFA/IFA
PCR
Other, specify: __________
Notes:
1. When requesting testing at VRDL, note influenza vaccination status of the case on the VRDL Specimen
Collection Form.
2. When requesting testing at VRDL, note whether patient is taking antiviral agents on the VRDL Specimen
Collection Form.
Local Health Department: ______________________________ LHD Contact: ___________________________
Phone: _______________________ Fax: ________________________ Date form filled out: ________________
PLEASE FAX TO CDPH VRDL at:
(510) 307-8599
(Attn: Janice Louie)

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