Guidelines for the public health management of gastroenteritis outbreaks due to norovirus or suspected viral agents in Australia

Appendix 5.3: Template for an initial report of a suspected outbreak of gastroenteritis

Page last updated: 2010

PDF printable version of Template for an initial report of a suspected outbreak of gastroenteritis (PDF 42 KB)

Date/time:

Public Health Officer:

Contact details:

Person notifying outbreak:

Position:

Telephone number:

Name of facility:

Address:

Facility Manager / Director:

Telephone number:

Fax number:

Email address:

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 UnitNo. of residentsLong term/short respite
Type of staff memberNo. employed by facilityNo. agency staff
Cleaner
Kitchen
Nurse
Care assistant
Other (specify)
Name of Agency/Agencies

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:

Residents:

Total number of residents affected so far:

DateNo. of residents who became unwell on that dayLocation
(e.g. wing/unit/room no.)
How many ill residents are in single rooms?

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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Staff:

Total number of staff members affected so far:
DateNo. of staff who became
unwell on that day
Type of staff (e.g. cleaner, kitchen, nurse, carer)Employee or agencyLocation where mostly work (e.g. wing / unit / room no.)
Number of visitors / family members reporting ill (if known):

Symptoms:

Presenting pattern of symptoms (including number of cases if available):

Diarrhoea only:Abdominal cramps only:
Vomiting only:Bloody diarrhoea:
Diarrhoea AND vomiting:Other:
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Clinical management of ill residents / children:

Date/time:

Public Health Officer:

Number of residents / children seen by a doctor:

Name of doctor(s):

Number of faecal specimens collected:

Date(s) 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:

Food preparation:

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:

Address:

Phone:

Contact person:

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

Common exposures:

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: