National Calicivirus Laboratory Form

Attachment K1.

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 Telephone: 404-639-1159

1600 Clifton Rd, N.E. Alternate: 404-639-3577

Atlanta, GA 30333 Fax: 404-639-3645

Date: __________________________________________

Agency: ________________________________________

Primary Contact for Epidemiologic Investigation Primary Contact for Clinical Specimens

Name: _________________________________________ Name:________________________________________

Telephone: _____________________________________ Telephone: ____________________________________

OUTBREAK INFORMATION

State Outbreak Identification Number
Outbreak Date
End Date
Event Date(s)
City
County
State
Setting (e.g., long-term care facility)
Transmission (e.g., person-to-person, food)
Suspected Source
Additional Comments:

Email: _________________________________________ Email: _______________________________________

ILLNESS CHARACTERISTICS

Number

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

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).

1 of 1