PDF printable version of Template for an initial report of a suspected outbreak of gastroenteritis (PDF 42 KB)
Public Health Officer:
Person notifying outbreak:
Name of facility:
Facility Manager / Director:
Description of facility:
Total number of residents:
Total number of staff at facility:
Age range of residents:
Number of units / wings in facility:
|Name of Unit||No. of residents||Long term/short respite|
|Type of staff member||No. employed by facility||No. agency staff|
Demographics of outbreak at time of notification:
Does the facility have an opinion as to the likely cause of the outbreak (e.g. viral or food-borne)?
Date/time of onset of first case of diarrhoea/vomiting:
Total number of residents affected so far:
|Date||No. of residents who became unwell on that day||Location|
(e.g. wing/unit/room no.)
How many ill residents are in shared rooms?
How many rooms have ensuites?
How many ill residents are high dependency?
(e.g. are incontinent or have dementia)
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Total number of staff members affected so far:
|Date||No. of staff who became|
unwell on that day
|Type of staff (e.g. cleaner, kitchen, nurse, carer)||Employee or agency||Location where mostly work (e.g. wing / unit / room no.)|
Presenting pattern of symptoms (including number of cases if available):
|Diarrhoea only:||Abdominal cramps only:|
|Vomiting only:||Bloody diarrhoea:|
|Diarrhoea AND vomiting:||Other:|
Clinical management of ill residents / children:
Public Health Officer:
Number of residents / children seen by a doctor:
Name of doctor(s):
Number of faecal specimens collected:
Name of pathology firm(s):
Results if known:
Number of residents hospitalised:
Number of residents died (if any) as result of outbreak:
Number of staff seen by a doctor:
If food is prepared on premises – is there a central kitchen?
Does the kitchen employ dedicated food prep / service?
Are any meals prepared by external contractors? Yes No
– If Yes: business/company name:
Do all areas of the facility receive food prepared from the same source?
Do staff members eat the same food as the residents? Yes No
Has there been a group function within the five days preceding the onset of the first symptoms? Yes No
If so, number of people exposed:
Residents: Staff: Visitors: