ࡱ> gifq  bjbjt+t+ &hAA~]8dXq 8XXXXX  $'XX(XX (((FXX((X,`ӣƵ Department of Health Communicable Disease Service PO 369 Trenton, NJ 08625-0369 INVESTIGATION/OUTBREAK INTAKE RECORDE - ______-______ Date Reported to LHD: _____/_____/_____ Date Reported to NJDOH: _____/_____/_____The intended use of this form is to assist disease investigators in collecting initial information from individuals calling to report outbreaks or other significant public health events. The intake record can be used to assist investigators to get important information on the initial phone call. This information can then be conveyed to NJDOH. Please remember that outbreaks and immediately reportable conditions defined by NJAC 8:57 should be reported via telephone when the report is received. Fax or email is not an acceptable mechanism to report these events.REPORTED BY FORMCHECKBOX  Local Health Department  FORMCHECKBOX  IP  FORMCHECKBOX  School Nurse  FORMCHECKBOX  LTC  FORMCHECKBOX  Physician  FORMCHECKBOX  Other: FORMTEXT      Organization Name: FORMTEXT      Contact Person: FORMTEXT      Phone #: FORMTEXT     -  FORMTEXT     -  FORMTEXT     Fax #: FORMTEXT     -  FORMTEXT     -  FORMTEXT     City: FORMTEXT      County: FORMTEXT      Email: FORMTEXT      Jurisdiction: FORMTEXT      EVENT FORMCHECKBOX  Gastrointestinal IllnessDescribe Situation:  FORMTEXT       FORMCHECKBOX  Respiratory FORMCHECKBOX  Rash FORMCHECKBOX  Other: FORMTEXT      Associated Location:Location:  FORMCHECKBOX  School/University  FORMCHECKBOX  Daycare  FORMCHECKBOX  LTC  FORMCHECKBOX  Acute Care Facility  FORMCHECKBOX  Restaurant  FORMCHECKBOX  Correctional Facility  FORMCHECKBOX  Other:  FORMTEXT ____________Name: FORMTEXT      Street Address: FORMTEXT      City: FORMTEXT      Zip: FORMTEXT      County: FORMTEXT      Contact: FORMTEXT      Phone #: FORMTEXT     -  FORMTEXT     -  FORMTEXT     Fax #: FORMTEXT     -  FORMTEXT     -  FORMTEXT     Email: FORMTEXT      SYMPTOMSLABORATORY INFORMATIONCommon Symptoms  FORMTEXT      Requested Labs: FORMTEXT      Date of Symptom Onset:Laboratory Sent to: FORMTEXT      First Onset Date: FORMTEXT   / FORMTEXT   / FORMTEXT   Most Recent Onset Date: FORMTEXT   / FORMTEXT   / FORMTEXT   Date of Test: FORMTEXT      Duration of Symptoms: FORMTEXT      Incubation Period (if known): FORMTEXT      # Specimens: FORMTEXT      # Total Population: FORMTEXT      # Ill Population: FORMTEXT      Type of Specimen: FORMTEXT      # Staff: FORMTEXT      # Ill Staff: FORMTEXT      Result: FORMTEXT      # Hospitalized: FORMTEXT      # Died: FORMTEXT       FORMTEXT      INVESTIGATIONCONTROL MEASURES RECOMMENDED / IMPLEMENTED FORMCHECKBOX  Travel History  FORMCHECKBOX  ID close contacts/Exposed  FORMCHECKBOX  Line List  FORMCHECKBOX  Surveillance/ Case Finding FORMCHECKBOX  Closure to New Admissions  FORMCHECKBOX  Chemoprophylaxis/Vaccination  FORMCHECKBOX  Quarantine/Isolation  FORMCHECKBOX  Cohorting of Ill/Staff FORMCHECKBOX  Restricted Access/Movement  FORMCHECKBOX  Education/Inservice  FORMCHECKBOX  Environmental Remediation  FORMCHECKBOX  Infection Control Precautions FORMCHECKBOX  Other:  FORMTEXT ____________Investigative Plans/Recommendations:  FORMTEXT      Other Agencies Involved/Notified:  FORMTEXT       CDS-36 AUG 14  \ ,-.<=>^_mnoz{@BV핡j5CJUmHnHj5CJUj5CJUjDCJUjCJUj\CJUjCJUjtCJUjCJU jCJU5CJ6CJCJCJ5CJ0 =D\ ,-4z$$TH4) $$$$TH4) $xx$%$$TH40)<$x$$$$$  =D\ ,-<=mn@Zdhjl  0 8 < J d j  " , 0 > X b f h j  D ^ h l n     ]-@hjl< J 0$$TH4Fp#)0$$TH@4F))$$$VXZdf       , . 0 8 : J L ` b d j l r t ׿׳קכ׏׃jb5CJUj5CJUjv5CJUj5CJUj5CJUj5CJUj5CJU5CJCJj5CJUmHnHj5CJUj,5CJU3   " , . > @ T V X b d D F Z \ ^ h j l n p 矩物j CJUj 5CJUjCJU jCJUCJ j45CJUj5CJUjL5CJUj5CJU5CJCJj5CJUj5CJUmHnH6  0 > f h L$$$\$$TH4֞Xh!))h j Y;$$TH4\8))$$$\$$TH4֞@H))  D l n Pbd%$$TH40 ) $%$$TH@40 )`$$$$$TH4) $$$$TH84) n  , 6 : < > @ B D F p  , J L x  "Nfjlx$(2LVZj .4V^bp b    ( * , 6 8 @ B   " , . 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