| Label/Short Name |
Description |
Value Set Code |
| HAB CDC Report ID |
CDC assigned report ID. |
(ALPHANUMERIC) |
| HAB State Report ID |
State assigned human case ID. |
(ALPHANUMERIC) |
| CDC Case ID |
CDC assigned case ID. |
(ALPHANUMERIC) |
| Report Date |
The date when the report was created. |
(DATE) |
| General Information: Human Description |
| Sex |
The sex of the human case. |
(SELECT FROM LIST) |
| Age (years) |
The age (in years) of the human case. |
(NUMERIC) |
| State of residence |
The state of residence of the human case. |
(SELECT FROM LIST) |
| General Information: Dates |
| Date of Exposure |
Did the person have an exposure on a single date or multiple dates? |
(SELECT FROM LIST) Single date/Multiple dates/Unknown |
| Date of First Exposure |
When was the first exposure? |
(DATE) |
| Time of First Exposure |
What time did the person have their first exposure? |
(TIME) |
| Date of Last Exposure |
When was the last exposure? |
(DATE) |
| Time of Last Exposure |
What time did the person have their last exposure? |
(TIME) |
| Date of Illness Onset |
When did illness begin? |
(DATE) |
| Time of Illness Onset |
What time did the illness onset begin? |
(TIME) |
| Date of Illness Recovery |
When did illness end? |
(DATE) |
| Time of Illness Recovery |
What time did the illness end? |
(TIME) |
| Date of Death |
When did the patient die? |
(DATE) |
| Time of Death |
What time did the death occur? |
(TIME) |
| Date of Notification to Authorities |
When were State,Territories,Local, or Tribal Health Authorities notified? |
(DATE) |
| Date of Interview |
When did the interview occur? |
(DATE) |
| Time of Interview |
What time did the interview occur? |
(TIME) |
| Human Exposure Information: Exposure Description |
| Exposure State(s) |
What state the did the exposure occur in? |
(MULTISELECT) |
| Exposure Count(ies) |
What county the did the exposure occur in? |
(MULTISELECT) |
| Exposure Setting(s) |
What setting the did the exposure occur in? |
(MULTISELECT) e.g. State Park/Private Residence |
| Specific Location Name(s) |
What is the specific name of the location where the exposure occured? |
(FREE TEXT) e.g. Cook's beach |
| Exposure Source |
What medium was the exposure source? |
(SELECT FROM LIST) e.g. Food/Water/Air/Other/Unknown |
| Exposure Activity |
What activities may have been associated with exposure? |
(SELECT FROM LIST) e.g. Recreation activities/Personal use/Commerical agriculture/Farming/Non-personal use/Aquaculture/Other/None/Unknown |
| Exposure Activity Description |
Description of exposure activity. |
(FREE TEXT) |
| Water Type |
Type of water body if applicable. |
(SELECT FROM LIST) e.g. Lake/Beach/Community water system/Other/Unknown |
| Food Type |
Type of food if applicable. |
(SELECT FROM LIST) e.g. Shellfish/Mussels/Finfish/Other/Unknown |
| Activity Duration |
How long did the activity last? |
(NUMERIC) |
| Activity Duration Unit |
What was the unit of time of the activity? |
(SELECT FROM LIST) Minutes/Hours/Days |
| Routes of Exposure |
What were the routes of exposure? |
(MULTISELECT) e.g. Ingestion/Inhalation/Skin Contact/Other/Unknown |
| Exposure Remarks |
Any additional information regarding the exposure(s)? |
(FREE TEXT) |
| Illness and Health Outcomes: Signs and Symptoms of Illness |
| Signs or symptoms |
What signs or symptoms of illness were experienced? |
(SELECT FROM LIST) e.g Lethargy/Ear Discharge/Rash/Other/Unknown |
| Time to Onset |
What was the time to illness onset? |
(NUMERIC) |
| Onset Unit |
What was the unit of time? |
(SELECT FROM LIST) Minutes/Hours/Days |
| Duration of Symptoms |
How long did the symptom(s) last? |
(NUMERIC) |
| Duration Unit |
What is the unit of time? |
(SELECT FROM LIST) Minutes/Hours/Days |
| Recurrence Following Mutiple Exposures |
Did the symptom reoccur after secondary, tertiary, etc exposures? |
Yes No Unknown (YNU) |
| Signs/Symptoms Consistent with Exposure |
Was the sign/symptom consistent with the route of exposure? |
Yes No Unknown (YNU) |
| Signs/Symptoms Consistent with Food Item |
If food was implicated, were the signs/symptoms consistent with foodborne fish/shellfish poisoning? |
Yes No Unknown (YNU) |
| Poisoning Description |
Characterization of foodborne poisoning symptoms. |
(SELECT FROM LIST) e.g. PSP/Ciguatera/Other |
| Signs/Symptoms Remarks |
Additional comments for signs/symptoms. |
(FREE TEXT) |
| Illness and Health Outcomes: Medical Care and Health Outcomes |
| Care from Non-medical Provider |
Did the person receive first aid care from a non-medical provider? |
Yes No Unknown (YNU) |
| Healthcare Visit |
Did the person visit a healthcare provider? |
Yes No Unknown (YNU) |
| Emergency Department Visit |
Did the person go to an emergency department? |
Yes No Unknown (YNU) |
| Poison Control Contact |
Was a poison control center contacted? |
Yes No Unknown (YNU) |
| Death |
Did the person die? |
Yes No Unknown (YNU) |
| Additional Medical/Health Outcome Information |
Do you have additional information about medical care or health outcomes for this person? |
Yes No Indicator (HL7) |
| Medical Care and Health Outcome Remarks |
Additional comments for medical care and health outcomes. |
(FREE TEXT) |
| Illness and Health Outcomes: Health History and Differential Diagnosis |
| Chronic Respiratory Disease |
Does the person have a history of chronic respiratory disease e.g. asthma, COPD? |
Yes No Unknown (YNU) |
| Tobacco Use |
Does the person have a history of tobacco use? |
Yes No Unknown (YNU) |
| Chronic Skin Disease |
Does the person have a history of skin disease e.g. psoriasis, eczema? |
Yes No Unknown (YNU) |
| Allergies |
Does this person have a history of allergies to food, medication, or other substances? |
Yes No Unknown (YNU) |
| Chronic Gastrointestinal Disease |
Does this person have a history of chronic gastrointestinal disease e.g. Crohn's disease? |
Yes No Unknown (YNU) |
| Chronic Kidney Disease |
Does this person have a history of chronic kidney disease e.g. caused by hypertension, diabetes, extended use of NSAIDs? |
Yes No Unknown (YNU) |
| Liver Disease |
Does this person have a history of liver disease e.g. hepatitis or cirrhosis? |
Yes No Unknown (YNU) |
| Chronic Neurologic Diseased |
Does this person have a history of chronic neurologic disease e.g. caused by diabetes? |
Yes No Unknown (YNU) |
| Immunocompromised |
Was the person immunocompromised due to medication or illness e.g. transplant recipient, diabetic? |
Yes No Unknown (YNU) |
| Alcohol Consumption within 24 Hours |
Did the person drink any alcohol within 24 hours prior to symptoms? |
Yes No Unknown (YNU) |
| Pregnant |
Was the person pregnant? |
|
| Skin Sensitivity due to Medication |
Was the person taking medications that increased skin sensitivity to the sun e.g. acne treatment, antibiotics? |
Yes No Unknown (YNU) |
| OTC Pain Medication |
Did the person frequently take over the counter (OTC) pain medication e.g. more than 5 times a week? |
Yes No Unknown (YNU) |
| Open Wounds |
Did the person have an open wound, sores, or broken skin at th etime of exposure? |
Yes No Unknown (YNU) |
| Communicable Diseases |
Had the person recently been exposed to any communicable diseases that cause similar signs or symptoms? |
Yes No Unknown (YNU) |
| Environmental Irritants |
Had the person recently been exposed to any environmental irritants that cause similar signs or symptoms e.g. poison ivy/oak? |
Yes No Unknown (YNU) |
| Other Causes Investigated |
Were other causes of the illness investigated? |
Yes No Unknown (YNU) |
| Other Environmental Sample Testing |
Were environmental samples tested to rule out other possible causes e.g. mushrooms? |
Yes No Unknown (YNU) |
| Clinical Testing |
| Clinical Specimen Testing |
Were clinical specimens tested? |
Yes No Unknown (YNU) |
| Type of Clinical Testing |
What type of clinical testing was performed to diagnose the illness or rule out other causes? |
(MULTISELECT) e.g. Bloodwork/Culture/Fecal analysis/Histopathology/Skin biopsy/Stomach content analysis/Toxicology/Urinalysis/X-ray/Other/Unknown |
| Classification |
What broad category of pathogen/toxin does the test result fall within? |
(SELECT FROM LIST) |
| Genus or Toxin |
What is the genus or toxin name? |
(SELECT FROM LIST) |
| Species |
What is the species name? |
(SELECT FROM LIST) |
| Subspecies/Serotype/Genotype |
What is the subspecies, serotype, or genotype? |
(SELECT FROM LIST) |
| Specimen Detection |
What type of clinical specimen tested positive? |
(SELECT FROM LIST) e.g. Blood/Stool/Tissue/Stomach Contents/Other |
| Concentration |
What was the concentration of the test result? |
(NUMERIC) |
| Concentration Unit |
What is the test result unit of concentration? |
(SELECT FROM LIST) |
| Test Type |
What was the type of test that was performed? |
(SELECT FROM LIST) |
| Clinical Testing Remarks |
Additional remarks regarding clinical testing? |
(FREE TEXT) |
| Supplemental Information |
| General Remarks |
Additional remarks regarding the human case. |
(FREE TEXT) |
| Attachments |
Additional attachments regarding the human case. |
(UPLOAD) e.g. word document,excel spreadsheet, image |
| Report Administration |
| Report Author |
Who is the author of the report? |
(FREE TEXT) |
| Reporting Site Name |
What is the name of the reporting site? |
(FREE TEXT) |
| Agency Name |
What is the name of the agency? |
(FREE TEXT) |
| Agency Contact Name |
Who is the agency contact? |
(FREE TEXT) |
| Agency Contact Title |
What is the agency contact's title? |
(FREE TEXT) |
| Agency Contact Phone |
What is the agency contact's phone number? |
(FREE TEXT) |
| Agency Contact Fax |
What is the agency contact's fax number? |
(FREE TEXT) |
| Agency Contact Email |
What is the agency contact's email address? |
(FREE TEXT) |
| Label/Short Name |
Description |
Value Set Code |
| HAB CDC Report ID |
CDC assigned report ID. |
(ALPHANUMERIC) |
| HAB State Report ID |
State assigned animal case ID. |
(ALPHANUMERIC) |
| CDC Case ID |
CDC assigned case ID. |
(ALPHANUMERIC) |
| Report Date |
The date when the report was created. |
(DATE) |
| General Information: Animal Description |
| Animal Category |
What is the category of animal(s) being reported? |
(SELECT FROM LIST) e.g. Domestic pet/Livestock/Wildlife/Other/Unknown |
| Animal Type |
What type of animal(s) are you reporting? |
(SELECT FROM LIST) Animal Type (FDD) |
| Animal Desciption |
Additional animal(s) description. |
(FREE TEXT) e.g. dog breed, cat breed, type of bird, amphibian, reptile, other, or other mammal |
| Single/Group of Animal(s) |
Does this illness report describe a single animal or a groupof animals e.g. school of fish, flocks, herds? |
(SELECT ONE) Single Animal/Group of Animals |
| Single Animal Age |
What is the age of the animal? |
(NUMERIC) |
| Single Animal Weight |
What is the weight of the animal (kg/lb)? |
(NUMERIC) |
| Single Animal Death |
Did the animal die? |
Yes No Unknown (YNU) |
| Single Animal Condition |
What condition was the animal found in? |
(MULTISELECT) e.g. Alive/Fresh/Scavenged/Decomposed/Unknown/Not applicable |
| Group Animals Affected |
How many animals were affected? |
(NUMERIC) |
| Group Animal Deaths |
Did any animals die? |
Yes No Unknown (YNU) |
| Group Animal Death Count |
How many dead animals were counted? |
(NUMERIC) |
| Group Animal Condition |
What condition were the animals found in? |
(MULTISELECT) e.g. Alive/Fresh/Scavenged/Decomposed/Unknown/Not applicable |
| General Information: Dates |
| Date of Exposure |
Did the person have an exposure on a single date or multiple dates? |
(SELECT FROM LIST) Single date/Multiple dates/Unknown |
| Date of First Exposure |
When was the first exposure? |
(DATE) |
| Time of First Exposure |
What time did the first exposure occur? |
(TIME) AM/PM |
| Date of Last Exposure |
When was the last exposure? |
(DATE) |
| Time of Last Exposure |
What time did the last exposure occur? |
(TIME) AM/PM |
| Date of Discovery |
When was the animal discovered? |
(DATE) |
| Time of Discovery |
What time was the animal discovered? |
(TIME) AM/PM |
| Date of Illness Onset |
When did the illness begin? |
(DATE) |
| Time of Illness Onset |
What time did the illness begin? |
(TIME) AM/PM |
| Date of Death |
When did the animal(s) die? |
(DATE) |
| Time of Death |
What time did the animal(s) die? |
(TIME) AM/PM |
| Date of Notification to Authorities |
When were State,Territories,Local, or Tribal Health Authorities notified? |
(DATE) |
| Date Remarks |
Additional remarks regarding the date. |
(FREE TEXT) |
| Animal Exposure Information: Exposure Description |
| Exposure State(s) |
What state did the exposure occur in? |
(MULTISELECT) |
| Exposure Count(ies) |
What county did the exposure occur in? |
(MULTISELECT) |
| Exposure Setting(s) |
What setting did the exposure occur in? |
(MULTISELECT) e.g. State Park/National Park/Private Residence |
| Specific location name(s) |
What is the specific name of the location where the exposure occurred? |
(FREE TEXT) e.g. Cook's beach |
| Exposure Activity |
What activities may have been associated with exposure? |
(SELECT FROM LIST) e.g. Recreation activites/Swimming/Other/None/Unknown |
| Exposure Activity Description |
Description of exposure activity. |
(FREE TEXT) |
| Water Type |
Type of water body if applicable. |
(SELECT FROM LIST) e.g. Lake/Beach/Community water system/Other/Unknown |
| Food Type |
Type of food if applicable. |
(SELECT FROM LIST) e.g. Shellfish/Mussels/Finfish/Other/Unknown |
| Activity Duration |
How long did the activity last? |
(Minutes/Hours/Days) |
| Routes of Exposure |
What were the routes of exposure? |
(MULTISELECT) e.g. Ingestion/Inhalation/Skin Contact/Other/Unknown |
| Exposure Remarks |
Any additional information regarding the exposure(s)? |
(FREE TEXT) |
| Signs of Illness and Health Outcomes: Signs of Illness |
| Signs |
What signs of illness were observed? |
(SELECT FROM LIST) e.g. Lethargy/Ear Discharge/Rash/Other/Unknown |
| Time to Onset |
What was the time to illness onset? |
(NUMERIC) |
| Onset Unit |
What was the unit of time? |
(SELECT FROM LIST) Minutes/Hours/Days |
| Duration of Signs |
How long did the sign(s) last? |
(NUMERIC) |
| Duration Unit |
What is the unit of time? |
(SELECT FROM LIST) Minutes/Hours/Days |
| Recurrence Following Mutiple Exposures |
Did the sign reoccur after secondary, tertiary, etc exposures? |
Yes No Unknown (YNU) |
| Signs Consistent with Exposure |
Was the sign consistent with the route of exposure? |
Yes No Unknown (YNU) |
| Signs of Illness and Health Outcomes: Medical Care and Health Outcomes |
| Veterinary Treatment |
Did the animal(s) receive veterinary medical care or treatment? |
Yes No Unknown (YNU) |
| Veterinary Admission |
Did the animal(s) get admitted to a veterinary facility? |
Yes No Unknown (YNU) |
| Additional Medical/Health Outcome Information |
Do you have additional information about medical care or health outcomes for the animal(s)? |
Yes No Indicator (HL7) |
| Medical Care and Health Outcome Remarks |
Additional information regarding the animal(s) medical care and health outcome. |
(FREE TEXT) |
| Signs of Illness and Health Outcomes: Health History and Differential Diagnosis |
| Pre-existing Conditions |
Did the animal(s) have any pre-existing conditions or disabilities? |
Yes No Unknown (YNU) |
| Medications |
Did the animal(s) receive any medications in the month before illness onset? |
Yes No Unknown (YNU) |
| Other Causes Investigated |
Were other causes of illness investigated? |
Yes No Unknown (YNU) |
| Other Environmental Sample Testing |
Were environmental samples tested to rule out other possible causes e.g. mushrooms? |
Yes No Unknown (YNU) |
| Health History and Differential Diagnosis Remarks |
Additional remarks regarding the animal(s) health history and differential diagnosis. |
(FREE TEXT) |
| Clinical Testing |
| Clinical Specimen Testing |
Were clinical specimens tested? |
Yes No Unknown (YNU) |
| Type of Clinical Testing |
What type of clinical testing was performed to diagnose the illness or rule out other causes? |
(MULTISELECT) e.g. Bloodwork/Culture/Fecal analysis/Histopathology/Skin biopsy/Stomach content analysis/Toxicology/Urinalysis/X-ray/Other/Unknown |
| Classification |
What broad category of pathogen/toxin does the test result fall within? |
(SELECT FROM LIST) |
| Genus or Toxin |
What is the genus or toxin name? |
(SELECT FROM LIST) |
| Species |
What is the species name? |
(SELECT FROM LIST) |
| Subspecies/Serotype/Genotype |
What is the subspecies, serotype, or genotype? |
(SELECT FROM LIST) |
| Specimen Detection |
What type of clinical specimen tested positive? |
(SELECT FROM LIST) e.g. Blood/Stool/Tissue/Stomach Contents/Other |
| Concentration |
What was the concentration of the test result? |
(NUMERIC) |
| Concentration Unit |
What is the test result unit of concentration? |
(SELECT FROM LIST) |
| Test Type |
What was the type of test that was performed? |
(SELECT FROM LIST) |
| Clinical Testing Remarks |
Additional remarks regarding clinical testing? |
(FREE TEXT) |
| Supplemental Information |
| General Remarks |
Additional remarks regarding the animal case. |
(FREE TEXT) |
| Attachments |
Additional attachments regarding the animal case. |
(UPLOAD) e.g. word document,excel spreadsheet, image |
| Report Administration |
| Report Author |
Who is the author of the report? |
(FREE TEXT) |
| Reporting Site Name |
What is the name of the reporting site? |
(FREE TEXT) |
| Agency Name |
What is the name of the agency? |
(FREE TEXT) |
| Agency Contact Name |
Who is the agency contact? |
(FREE TEXT) |
| Agency Contact Title |
What is the agency contact's title? |
(FREE TEXT) |
| Agency Contact Phone |
What is the agency contact's phone number? |
(FREE TEXT) |
| Agency Contact Fax |
What is the agency contact's fax number? |
(FREE TEXT) |
| Agency Contact Email |
What is the agency contact's email address? |
(FREE TEXT) |
| Label/Short Name |
Description |
Value Set Code |
| HAB CDC Report ID |
CDC assigned report ID. |
(ALPHANUMERIC) |
| HAB State Report ID |
State assigned animal case ID. |
(ALPHANUMERIC) |
| CDC Case ID |
CDC assigned case ID. |
(ALPHANUMERIC) |
| Report Date |
The date when the report was created. |
(DATE) |
| General Information: Dates |
| Date of First Bloom |
When was the bloom first observed? |
(DATE) |
| Other Event |
Reason for report, if no date of first bloom. |
(SELECT FROM LIST) e.g. Foodborne intoxication/Other evidence of Harmful algal toxicity |
| Date of Notification to Authorities |
When were State,Territories,Local, or Tribal Health Authorities notified? |
(DATE) |
| Date Remarks |
Additional information regarding dates. |
(FREE TEXT) |
| General Information: Geographic Description |
| State/Jurisdiction |
What state(s)/jurisdiction(s) did the event occur in? |
(SELECT FROM LIST) |
| Count(ies) |
What count(ies) did the event occur in? |
(MULTISELECT) |
| Other States Affected |
Did an algal bloom impact water quality in any other states? |
Yes No Unknown Not applicable |
| Other States |
What other states were affected? |
(SELECT FROM LIST) |
| Official Name of Water Body |
What is the official name of the water body? |
(FREE TEXT) |
| Common Name of Water Body |
What is the common name of the water body? |
(FREE TEXT) |
| Specific Location Name(s) |
What is the specific name of the location? |
(FREE TEXT) e.g. Cook's beach |
| Nearest City/Town |
What is the nearest City/Town? |
(FREE TEXT) |
| Latititude |
What is the latitude of the event? |
(NUMERIC) |
| Longitude |
What is the longitude of the event? |
(NUMERIC) |
| Hydrologic Unit Code |
What is the hydrologic unit code? |
(MULTISELECT) |
| Water Type |
What water type did the event occur in? What was the type of water body? |
(SELECT FROM LIST) |
| Water Salinity |
What sality was the water body? |
(SELECT FROM LIST) e.g. Fresh/Brackish/Salt |
| Water Body of Bloom |
What is the water body, or if applicable, the area of the water body where the bloom was located, used for? |
(MULTISELECT) e.g. Agriculture/Aquaculture/Industrial-Occupational/Public drinking water system/Raw water, non-potable/Recreation/Other/None/Unknown |
| Geographic Description Remarks |
Additional information regarding geographic description. |
(FREE TEXT) |
| Bloom Description: Health Advisories/Warnings |
| Type of Advisory/Warning |
If an advisory/warning was issued, what was type of advisory/warning? |
(SELECT FROM LIST) e.g. Health advisory/No contact warning/Water body closure (recreational activity)/Water body closure (fish/shellfish)/Other |
| Advisory/Warning Response |
Was there a response issued for the type of advisory/warning? |
Yes No Unknown Not applicable |
| Advisory/Warning Agency |
What agency if applicable issued the advisory/warning? |
(FREE TEXT) |
| Advisory Criteria/Reason |
What criteria/reason was the advisory issued for? |
(FREE TEXT) |
| Advisory/Warning Start Date |
What date did the advisory/warning begin? |
(DATE) |
| Advisory/Warning End Date |
What date did the advisory/warning end? |
(DATE) |
| Bloom Description: Observational Data |
| Date Documented |
What day did the event occur? |
(DATE) |
| Documented By |
Who documented the event? |
(SELECT FROM LIST) e.g. General public, State, Local, other |
| Scum/Algal Matter Observed |
Was any scum or algal matter observed? |
Yes No Unknown (YNU) |
| Water Color |
What color was the water? |
(SELECT FROM LIST) e.g. Red/Yellow/Green |
| Water Clarity |
What was the water clarity? |
(SELECT FROM LIST) e.g. Clear/Muddy |
| Water Odors |
Did the water have an odor? |
Yes No Unknown (YNU) |
| Water Flow |
Was there water flow? |
(SELECT FROM LIST) Moving/Stagnant/Unknown |
| Tidal Conditions |
Were there tidal conditions? |
(SELECT FROM LIST) High tide/Low Tide/Not applicable |
| Laboratory Testing: Algae, Algal Toxins or Components Testing |
| Samples Tested |
What was tested for algae, algal toxins or components? |
(MULTISELECT) e.g. Air/Algae/Finished drinking water/Food/Raw water, ambient/No testing/Other/Unknown |
| Reason Samples Tested |
If testing was conducted, why was it tested? |
(MULTISELECT) e.g. Fish illness,kill/Animal health event response/Citizen complaint/Human health event response/Monitoring/Odor/Other/Unknown |
| Water Testing |
If water testing was performed, were any of the following tests conducted? |
(MULTISELECT) e.g. Algae/Algal toxins/Chlorophyll/Copper sulfate/Enterococci/Fecal coliforms/Other |
| Laboratory Testing: Laboratory Results |
| Classification |
What broad category of pathogen/toxin does the test result fall within? |
(SELECT FROM LIST) |
| Genus or Toxin |
What is the genus or toxin name? |
(SELECT FROM LIST) |
| Species |
What is the species name? |
(SELECT FROM LIST) |
| Subspecies |
What is the subspecies? |
(SELECT FROM LIST) |
| Sample Detection |
What type of environmental sample tested positive? |
(SELECT FROM LIST) e.g. Blood/Stool/Tissue/Stomach Contents/Other |
| Sample Description |
Description of the environmental sample that tested postitive. |
(FREE TEXT) |
| Concentration |
What was the concentration of the test result? |
(NUMERIC) |
| Concentration Unit |
What was the test result unit of concentration? |
(SELECT FROM LIST) |
| Test Type |
What was the type of test that was performed? |
(SELECT FROM LIST) |
| Sample Collection Date |
What date were the samples collected? |
(DATE) |
| Sample Collection Time |
What time were the samples collected? |
(TIME) |
| Laboratory Testing Remarks |
Additional remarks regarding laboratory testing? |
(FREE TEXT) |
| Links to Other Systems: Links to Other Data Systems Containing Information About the Bloom |
| System Type |
What the type of system? |
(SELECT FROM LIST) Federal/State |
| System Name |
What is the system name? |
(SELECT FROM LIST) e.g. NPS HAB surveillance/NORS |
| System Report ID Number |
What is the system report ID number? |
(FREE TEXT) |
| Brief Description of Linked Information |
Descripton of linked information. |
(FREE TEXT) |
| Supplemental Information |
| General Remarks |
Additional remarks regarding the environmental event. |
(FREE TEXT) |
| Attachments |
Additional attachments regarding the environmental event. |
(UPLOAD) e.g. word document,excel spreadsheet, image |
| Report Administration |
| Report Author |
Who is the author of the report? |
(FREE TEXT) |
| Reporting Site Name |
What is the name of the reporting site? |
(FREE TEXT) |
| Agency Name |
What is the name of the agency? |
(FREE TEXT) |
| Agency Contact Name |
Who is the agency contact? |
(FREE TEXT) |
| Agency Contact Title |
What is the agency contact's title? |
(FREE TEXT) |
| Agency Contact Phone |
What is the agency contact's phone number? |
(FREE TEXT) |
| Agency Contact Fax |
What is the agency contact's fax number? |
(FREE TEXT) |
| Agency Contact Email |
What is the agency contact's email address? |
(FREE TEXT) |