Respiratory Illness Outbreak Line List

Inspection-style line list for nursing homes to track resident and staff respiratory illness cases by symptom onset, exposure, testing, isolation status, and outbreak control actions.

Inspection Details

• Facility name recorded
• Inspection date and time recorded
• Outbreak review period defined
  Enter the date range covered by the line list, such as the current outbreak period or surveillance window.
• Reviewer name and role recorded

Case Line List Completeness

• Unique case identifier assigned
• Case type identified as resident or staff
• Symptom onset date recorded
• Primary respiratory symptoms documented
• Case status updated
• New cases added for the current day
• Line list updated for all known cases

Exposure, Testing, and Clinical Status

• Known exposure source documented
• Testing status recorded
• Specimen collection date recorded when tested
• Hospitalization or ED transfer status recorded
• Outcome or current condition documented

Isolation, Cohorting, and Work Restrictions

• Resident isolation or cohorting status documented
• Staff work restriction or exclusion status documented
• PPE use aligned to respiratory precautions
• Symptomatic resident transfer or appointment precautions documented
• Isolation start date recorded

Outbreak Control Actions and Reporting

• Public health notification completed when required
• Physician, resident representative, or responsible party notified as applicable
• Corrective actions documented for gaps in surveillance or infection control
• Reference document used for outbreak tracking
• Inspector signature