COVID-19 Outbreak Reporting Form
Name of the Facility
Address of the Facility
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of the Facility
Please enter a valid phone number.
Primary Contact Person
First Name
Last Name
Phone Number of the Primary Contact Person
Please enter a valid phone number.
Type of Report
Initial report
Final report
Date and Time Reported
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Type of Facility
Long-term (Nursing home)
Health Care (hospital, dialysis, dental)
Government (police, military)
Service Industry (grocery, restaurant)
Essential Frontline Worker
Other
Geographic Location
Multi-county outbreak
Multi-state outbreak
Other
Statistical Report
Count
Number of Tested
Number of cases positive
Number of cases suspected
Deaths
Employees/staff/workers
Contractors
Third-party workers
Vendors
Other
Number of workers who are positive for COVID-19
Submit
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