Chester County Congregate Care COVID Intake Form

Please complete this form

At the start of a respiratory outbreak
During the outbreak, on a weekly basis, to report COVID, influenza and RSV numbers

For COVID outbreak: Defined as 1 COVID case in the facility

For influenza outbreak: Defined as 2 cases of influenza in the facility, at least one case which is laboratory confirmed

For RSV: We are not tracking outbreaks, but rather RSV co-infections during a COVID or influenza outbreak

Once you submit this form at the start of an outbreak, the Chester County Health Department will reach out to you.

Submit new case counts weekly during the outbreak. If the facility has no new cases in the 7 (for influenza) or 14 (for COVID) days since the last case, please fill out the corresponding field and make a note of it in the Notes section of this form.

The outbreak is considered closed if it has been 14 days since the last COVID case or 7 days since the last influenza case (symptom onset date or test date).

Today's Date*

Facility Type*

Name of Facility*

Facility Address*

Street Address

Street Address Line 2

CityState

Zip Code

Facility Point of Contact Name*

First NameLast Name

Facility Point of Contact Phone Number*

Please enter a valid phone number.

Facility Point of Contact Email Address*

example@example.com

Current Resident Census*

Current Staff Census*

Please complete number of new cases since last report for this outbreak. Please complete all boxes, entering 0 if no cases.*

	COVID	Influenza	RSV
New Cases among Residents (since last report)
New Cases among Staff (since last report)

Which specific units/areas of your facility are affected by the outbreak?

Which outbreak response method is being implemented? Select all that apply.*

Is this outbreak closed (14 days since date of last COVID case or 7 days since last influenza case)?*

YesNo, the outbreak is still open

Has Facility been in contact with the RISE Team in the past?*

YesNoNot aware of RISE Team

Share any additional notes below, including any challenges to outbreak response

Chester County Health Department Respiratory Illness Reporting Form