Viral Gastroenteritis Outbreak Submission Form

National Disease Surveillance Program - II. Disease Summaries

Attachment Y_Viral Gastroenteritis Outbreak Submission Form

Att Y_ Viral Gastroenteritis Outbreak Submission Form

OMB: 0920-0004

Document [docx]
Download: docx | pdf

NCL-3003

Form Approved

OMB No. 0920-0004

Centers for Disease Control and Prevention, Division of Viral Diseases, National Calicivirus Laboratory


Viral Gastroenteritis Outbreak Submission Form


National Calicivirus Laboratory

DASH Unit 186

Centers for Disease Control and Prevention Telephone: 404-639-1159

1600 Clifton Rd, N.E. Alternate: 404-639-3577

Atlanta, GA 30333 Fax: 404-639-3645


Date: __________________________________________

Agency: ________________________________________


Primary Contact for Epidemiologic Investigation Primary Contact for Clinical Specimens

Name: _________________________________________ Name:________________________________________

Telephone: _____________________________________ Telephone: ____________________________________

Shape1

OUTBREAK INFORMATION



State Outbreak Identification Number


Outbreak Date


End Date


Event Date(s)


City


County


State


Setting

(e.g., long-term care facility)


Transmission

(e.g., person-to-person, food)


Suspected Source


Additional Comments:


Email: _________________________________________ Email: _______________________________________

Shape2

ILLNESS CHARACTERISTICS

Number

Sick


Susceptible


Sought Care


Admitted to hospital


Deaths


Fever


Diarrhea


Vomitus


Duration

(range, in hours)


Incubation time

(range, in hours)




Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0004).

1 of 1

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorA satisfied Microsoft Office User
File Modified0000-00-00
File Created2021-01-22

© 2024 OMB.report | Privacy Policy