The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

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Respiratory Outbreak

This form should be used to report respiratory disease outbreaks in the long-term care (nursing home) setting only. To report respiratory disease outbreaks in other settings please call the disease reporting telephone hotline (1-800-362-2736) during normal business hours.

The option "" can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?

Study ID

Once this form is completed, you will be contacted by a public health official within one business day.

Select the name of your facility:

* must provide value

Please type the name of your facility:

* must provide value

County where your facility is located:

* must provide value

Name of person submitting this report:

* must provide value

Preferred call back number:

* must provide value

Preferred email address:

* must provide value

HAI case number: ______

Date Respiratory illness outbreak reported to HHS

M-D-Y

Date and Time Report Submitted

M-D-Y

Outbreak Name

Outbreak number

Outbreak confirmation status

Confirmed respiratory illness outbreak

Suspected respiratory illness outbreak (unable to complete confirmation testing)

Not a respiratory illness outbreak (Other respiratory illness or illness identified that is not covered under the investigation protocol)

Illness covered under investigation protocol but the facility did not meet the minimum number of cases threshold

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Please select the respiratory virus that are a confirmed outbreak (2 or more lab confirmed cases). Please select all that apply if more than one were laboratory confirmed.

influenza

COVID-19

RSV

Parainfluenza

Human Metapneumovirus

Adenovirus

Coronavirus (other than COVID-19)

Human Rhinovirus-Enterovirus

Other respiratory diseases (please specify)

Please specify other pathogen that tested positive

Facility that submitted the report is not a nursing home (i.e. assissted living home)

Please specify the diagnosis if determined to not be Influenza, RSV, Parainfluenza or Human Metapneumovirus

CADE HAI Staff working on respiratory illness outbreak

Other CADE staff working on respiratory illness outbreak

Outbreak Recommendations Made By (Please include LPHA staff name)

How many residents are currently displaying symptoms of a respiratory infection?

Number of total residents at the facility

How many facility staff are currently displaying symptoms of a respiratory infection?

Number of total staff at the facility

First Onset Date

M-D-Y

Was the index case (first case) in a resident or staff member of your facility?

Have any residents or staff tested positive for the following respiratory viruses? select all that apply

influenza

COVID-19

RSV

Parainfluenza

Human Metapneumovirus

Adenovirus

Coronavirus (other than COVID-19)

Human Rhinovirus-Enterovirus

Other respiratory diseases (please specify)

No resident nor staff have tested positive for a respiratory disease

STOP if you are using this form to report a suspected case of Severe acute respiratory syndrome (SARS). SARS is immediately reportable. Call the 24/7 disease reporting telephone hotline: 1-800-362-2736.

Please specify any other respiratory diseases staff or residents have tested positive for in your facility?

Number of residents that have tested positive for influenza:

Number of staff that have tested positive for influenza:

Date of index influenza case positive:

M-D-Y

Date of last influenza case positive:

M-D-Y

Number of residents that have tested positive for COVID-19:

Number of staff that have tested positive for COVID-19:

Date of index COVID-19 case positive:

M-D-Y

Date of last COVID-19 case positive:

M-D-Y

Number of residents that have tested positive for RSV:

Number of staff that have tested positive for RSV:

Date of index RSV case positive:

M-D-Y

Date of last RSV case positive:

M-D-Y

Number of residents that have tested positive for Parainfluenza:

Number of staff that have tested positive for Parainfluenza:

Date of index Parainfluenza case positive:

M-D-Y

Date of last Parainfluenza case positive:

M-D-Y

Number of residents that have tested positive for Human Metapneumovirus:

Number of staff that have tested positive for Human Metapneumovirus:

Date of index Human Metapneumovirus case positive:

M-D-Y

Date of last Human Metapneumovirus case positive:

M-D-Y

Number of residents that have tested positive for Adenovirus:

Number of staff that have tested positive for Adenovirus:

Date of index Adenovirus case positive:

M-D-Y

Date of last Adenovirus case positive:

M-D-Y

Number of residents that have tested positive for a Coronavirus (other than COVID-19):

Number of staff that have tested positive for a Coronavirus (other than COVID-19):

Date of index Coronavirus (other than COVID-19) case positive:

M-D-Y

Date of last Coronavirus (other than COVID-19) case positive:

M-D-Y

Number of residents that have tested positive for Human Rhinovirus-Enterovirus:

Number of staff that have tested positive for Human Rhinovirus-Enterovirus:

Date of index Human Rhinovirus-Enterovirus case positive:

M-D-Y

Date of last Human Rhinovirus-Enterovirus case positive:

M-D-Y

Number of residents that have tested positive for other respiratory diseases:

Number of staff that have tested positive for Other respiratory diseases:

Date of index other respiratory diseases case positive:

M-D-Y

Date of last other respiratory diseases case positive:

M-D-Y

Date of most recent resident positive:

M-D-Y

Feel free to write a short message or note with any other questions or concerns you may have regarding respiratory disease in your facility:

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While waiting for a public health official to contact you, if you have not already, please review the CDC Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities at https://www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm

While waiting for a public health official to contact you, if you have not already, please review the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html

While waiting for a public health official to contact you, if you have not already, please review CDC RSV For Healthcare Providers at https://www.cdc.gov/rsv/clinical/index.html

While waiting for a public health official to contact you, if you have not already, please review CDC Human Parainfluenza Viruses (HPIVs) Clinical Overview at https://www.cdc.gov/parainfluenza/hcp/clinical.html

While waiting for a public health official to contact you, if you have not already, please review CDC Human Metapneumovirus (HMPV) at https://www.cdc.gov/ncird/human-metapneumovirus.html

Have you already spoken with the Iowa HHS Nurse Clinician (Chris Barten, Dee Vaage, Lisa Vitale, Tyra Goss, or Abby Hough) assigned to your area regarding these cases at your facility?

* must provide value

Yes

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An Iowa HHS staff member will send an email with additional guidance and recommendations to the email address you provided. In addition to this email, would you like to receive a phone call providing additional assistance at the phone number you provided?

* must provide value

Yes

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Remember to hit submit before closing this form.

Percent of residents vaccinated

Percent of staff vaccinated

Send Suspected Outbreak report to CADE? (Please see note below the field before selecting "yes")

Yes

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Send Outbreak Confirmation report to CADE? (Please see note below the field before selecting "yes")

Yes

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Was a line list of cases submitted from the facility?

Yes

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Final line list upload

Upload file

Final onset date

M-D-Y

Outbreak end date

M-D-Y

Total residents ill at close of outbreak

Total staff ill at close of outbreak

Final total of residents hospitalized

Final total of resident deaths

Notes (optional)

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Were specimens sent for testing to a clinical lab, SHL, or both?

Clinical lab

SHL

Both

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Name of Clinical Lab

Number of COVID-19 positive clinical lab results

Number of COVID-19 positive test results from SHL

Number of RSV positive clinical lab results

Number of RSV positive test results from SHL

Number of Parainfluenza positive clinical lab results

Number of Parainfluenza positive test results from SHL

Number of Human Metapneumovirus positive clinical lab results

Number of Human Metapneumovirus positive test results from SHL

Number of Adenovirus positive clinical lab results

Number of Adenovirus positive test results from SHL

Number of Coronavirus (other than COVID-19) positive clinical lab results

Number of Coronavirus (other than COVID-19) positive test results from SHL

Number of Human Rhinovirus-Enterovirus positive clinical lab results

Number of Human Rhinovirus-Enterovirus positive test results from SHL

Number of ______ positive clinical lab results

Number of ______ positive test results from SHL

Non-Influenza lab testing details/notes (optional)

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Flu test facility site (if not SHL)

Number Flu A positive

Number Flu B positive

Number Flu A and B negative

Number of other results

Were any of the positive flu results at clinical labs done by molecular methods?

Yes

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Clinical lab testing details (optional)

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Number of specimens received at SHL

Number Flu A positive at SHL

Number Flu B positive at SHL

Number Flu A H1N1 positive

Number Flu A H3 positive

Number Flu B Victoria Positive

Number Flu B Yamagata Positive

Number negative for all pathogens tested at SHL

Number Other results at SHL

SHL testing details/notes (optional)

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Any additional notes or comments related to investigation (i.e. lab results, investigation, etc.)

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Investigation closed?

Ongoing

Closed

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Send final Respiratory Illness numbers to Andy?

Yes

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.