Chester County Congregate Care COVID Intake Form

Chester County Health Department Respiratory Illness Outbreak Intake Form
Please complete this form at the start of a respiratory outbreak in your facility.

DEFINITIONS

COVID-19 Outbreak:
- Residents - 2 or more facility-acquired probable or confirmed COVID-19 cases in a single unit within a 7-day period
- Staff – 2 or more probable or confirmed COVID-19 cases in health care personnel who were working in the same unit while infectious within a 7-day period
Influenza Outbreak:
- One resident with laboratory-confiirmed influenza, AND at least one additional resident with Influenza-Like Illness (ILI)
OR
- Two or more residents with Influenza-Like Illness (ILI) within 72 hours of each other. Influenza-like illness (ILI) = fever (>100°F) plus new cough or sore throat
About RSV - We are not tracking outbreaks, but rather RSV co-infections during a COVID-19 or influenza outbreak.

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

The outbreak is considered OVER if it has been 14 days since the last COVID-19 case or the last influenza case (using the symptom onset date or test date as the first day).

When the outbreak is closed, please complete the Respiratory Illness Outbreak Final Report Form on our website.
Today's Date*

MonthDayYear
Name of Facility*
City/Town where Facility is Located*
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*
Date First Resident or Staff became Ill:

MonthDayYear
Date

Please complete number of cases at the start of the outbreak. Please complete all boxes, entering 0 if no cases.*

	COVID	Influenza	RSV
New Cases among Residents
New Cases among Staff

Which specific units/areas of your facility are affected by the outbreak?
Share any additional notes below, including if you are requesting assistance
Should be Empty:

Chester County Health Department Respiratory Illness Outbreak Intake Form