Viral Gastroenteritis Outbreak Submission Form

NCL-3003

Form Approved
OMB No. 0920-0004

Centers for Disease Control and Prevention, Division of Viral Diseases, National Calicivirus Laboratory

Viral Gastroenteritis Outbreak Submission Form
National Calicivirus Laboratory
DASH Unit 186
Centers for Disease Control and Prevention
1600 Clifton Rd, N.E.
Atlanta, GA 30333

Telephone:
Alternate:
Fax:

404-639-1159
404-639-3577
404-639-3645

Date: __________________________________________
Agency: ________________________________________

Primary Contact for Epidemiologic Investigation

Primary Contact for Clinical Specimens

Name: _________________________________________

Name:________________________________________

Telephone: _____________________________________

Telephone: ____________________________________

Email: _________________________________________

Email: _______________________________________

OUTBREAK INFORMATION

ILLNESS CHARACTERISTICS
Number

State Outbreak
Identification Number

Sick

Outbreak Date

Susceptible

End Date

Sought Care

Event Date(s)
City
County
State
Setting
(e.g., long-term care
facility)
Transmission
(e.g., person-toperson, food)

Admitted to hospital
Deaths
Fever
Diarrhea
Vomitus
Duration
(range, in hours)
Incubation time
(range, in hours)

Suspected Source
Additional Comments:

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a
collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0004).
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