Initial Notification:                                                  Update:  1    2    3    4    5    6    Final

Particulars taken by (name):                      at  Provinical Public Laboratory

on (date):                                              at            am/pm

From:                                            Health Unit/Institution:
 

Outbreak Number:                                             (HU # - HU File # - Year)

Location:                                                                                        City/Town:

Source/Event:

# Persons Ill:            # Hospitalized:          (Hospital                                                             )    Died:

# Persons at Risk:                           Patients/Patrons:                                            Staff:

Onset date:                                 (index case)

Major Symptoms: (please circle)              Nausea                    Vomiting                  Abdominal cramps                     Headache              Fever                       Chills                      Watery diarrhea                       Bloddy diarrhea              Prostration                Other:

Number of Specimens Expected:   Stool                    Serum                        Food                         Water                    Swab

Number of outbreak kits (stools) required initially:

Types of food being sent:

Total Symptomatic # of specimens received:   Stool                    Serum      # of related samples:         Food                    Water                      Swab               Other

Results, if any:

Comments, if any:

Copies to:   1. Director, Laboratory Services Branch                           Fax (416) 235-6063                  2. Physican Manager, Public Health Branch                      Fax (416) 965-0911

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