Respiratory Illness Intake Survey

This form can be used to report respiratory illness (e.g. COVID-19, Influenza, RSV) to PHSKC. If you are reporting a different notifiable condition or disease, please call our main Public Health Communicable Disease line at 206-296-4774.

Healthcare facilities (including LTCFs) must report positive cases of COVID-19 to PHSKC within 24 hours according to the Washington Administrative Code (WAC).

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Date submitted:

M-D-Y H:M

Status:

This is a non-healthcare facility reporting Non-COVID. Transfer this report to CDDB (do not enter in REDCap).

Why does this record need PPM review (Admin)?

What was the outcome/conclusion from the review (PPM)?

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Reviewed by:

Database Record ID:

School Reporting REDCap Record ID:

Respiratory Virus REDCap URL link

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Date reviewed:

M-D-Y

Which of the following best fits your facility?

* must provide value

Healthcare (e.g. hospital, clinic*, long term care, home health/care, supported living facility)

EMS/Fire

Homeless services including shelters

Correctional facility (including prison, jail, work release)

K-12 school, childcare/preschool, youth camp/activity

Youth Sports (not school-affiliated)

College/University/Vocational school

Non-healthcare industry or workplace

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Please specify healthcare facility type:

* must provide value

Which services do you provide at your facility:

* must provide value

Assisted living (with or without memory care)

Skilled nursing facility (SNF)

Independent living or Senior Housing (50+)

Adult Family Home

Supported Living

Other

Please specify homeless-service facility type:

* must provide value

Please specify correctional facility type:

* must provide value

Please specify youth-related facility type:

* must provide value

Type of industry:

* must provide value

What type of government/public administration industry?

* must provide value

What type of goods-producing industry?

* must provide value

What type of service-providing industry?

* must provide value

If other, please specify:

School District

* must provide value

Auburn School District - Please select school:

Bellevue School District - Please select school:

Enumclaw School District - Please select school:

Federal Way School District - Please select school:

Highline School District - Please select school:

Issaquah School District - Please select school:

Kent School District - Please select school:

Lake Washington School District - Please select school:

Mercer Island School District - Please select school:

Northshore School District - Please select school:

Renton School District - Please select school:

Riverview School District - Please select school:

Seattle Public Schools - Please select school:

Shoreline School District - Please select school:

Skykomish School District - Please select school:

Snoqualmie Valley School District - Please select school:

Tahoma School District - Please select school:

Tukwila School District - Please select school:

Vashon Island School District - Please select school:

Please select your school:

Is this the first report submitted to Public Health regarding this facility in the past 14 days?

* must provide value

Yes

Unsure

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Has your facility been contacted by a Public Health investigator in the past 14 days?

*if yes, we ask that you follow the guidance/instructions provided by your investigator and do not fill out this form. Please reach out to the investigator directly if you have additional needs.

* must provide value

Yes

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Reason for report:

* must provide value

COVID-19: Report cases/suspected facility transmission

Non-COVID: Report cases/suspected transmission of influenza, RSV, or other respiratory illness

Request a free, non-regulatory Infection Control and Response visit

If other reason for report, please describe:

Please select all situations that apply for COVID-19 cases and/or suspected transmission at your facility:

* must provide value

SNF ONLY- report 10% total residents are hospitalized due to COVID OR 5% total residents died of COVID

Facility requests assistance from a public health investigator

None of the above

Please note that facilities reporting COVID-19 cases and outbreaks to public health will only be contacted if one of the listed situations above applies to your facility.

Please select all situations that apply for non-COVID-19 respiratory illness cases and/or suspected transmission at your facility:

* must provide value

SNF ONLY- report 10% total residents are hospitalized OR 5% total residents died due to a respiratory illness other than COVID-19

Facility requests assistance from a public health investigator

None of the above

Please note that facilities reporting non-COVID respiratory illness cases and outbreaks to public health will only be contacted if one of the listed situations above applies to your facility.

You requested a follow up from a public health investigator. Please briefly describe your specific concerns/questions:

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Encampment/Tent City location name or description (e.g. cross-streets):

Facility name

* must provide value

Street address

* must provide value

City

* must provide value

Zip code

If reporting individual death, please fill out the following contact information for person reporting death:

Affiliated facility of contact person:

Contact person - first name

* must provide value

Contact person - last name

* must provide value

Contact person title

Affiliation with facility:

Facility organizational leadership*

Employee/Staff

Client

Concerned citizen

Other

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Please describe your affiliation with the facility listed on this form:

Contact phone

* must provide value

Contact email

* must provide value

Contact fax

Total number of employees who tested positive for COVID-19 in the past 14 days:

* must provide value

Number of employees who have recently tested positive for COVID-19 and who you have not previously reported to Public Health?

i.e. this is the first time you are notifying PHSKC of this case

* must provide value

Total number of clients (e.g. children/students or residents) who tested positive for COVID-19 in the past 14 days:

* must provide value

Number of clients (e.g. children/students or residents) who recently tested positive for COVID-19 and who you have not previously reported to Public Health?

i.e. this is the first time you are notifying PHSKC of this case

* must provide value

Symptom onset date of first known COVID-19 positive case (if known):

* must provide value

M-D-Y

Symptom onset date of most recent known COVID-19 positive case (if known):

* must provide value

M-D-Y

Have any positive COVID-19 cases been hospitalized?

Yes

Unknown

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How many COVID-19 cases have been hospitalized?

Have any positive COVID-19 cases died?

Yes

Unknown

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How many COVID-19 cases have died?

Which illness are you reporting?

* must provide value

Influenza

Respiratory Syncytial Virus (RSV)

Other respiratory illness

Undiagnosed respiratory illness

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Please provide more details regarding the illness diagnosis or observed symptoms:

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Total number of employees who tested positive for ______ in the past 14 days:

* must provide value

Total number of clients (e.g. children/students or residents) who tested positive for ______ in the past 14 days:

* must provide value

Symptom onset date of first known ______ positive case (if known):

* must provide value

M-D-Y

Symptom onset date of most recent known ______ positive case (if known):

* must provide value

M-D-Y

Have any positive ______ cases been hospitalized?

Yes

Unknown

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How many ______ cases have been hospitalized?

Have any positive ______ cases died?

Yes

Unknown

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How many ______ cases have died?

Please add additional comments or concerns not captured in the above fields:

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Public Health is not requesting case level data at this time but may need it in the future. Please keep a list of all positive cases at your facility (including full name, date of birth, affiliation) to share with a Public Health investigator upon request.

Please submit person-level data with your report. This helps investigators respond more efficiently to any potential clusters or concerns at your facility.

*Please note, this is NOT the appropriate form to report lab results. This information is only used for assisting in the facility investigation. To report antigen point of care test results, please use this link.

REDCap is HIPAA-compliant and highly secure. Any information provided here will only be shared with the investigation team following up with your facility.

How do you want to enter person-level information?

Upload case list

Enter person-level information directly in form

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Please use this template to prepare your case list and enter as much information as you have available. If you already have a template that you would prefer to use, please make sure you include the following critical fields:

First Name
Last Name
Date of Birth
Affiliation with facility (staff, resident etc.)
Date of first positive test

Thank you!

Attachment:Positive Case List.xlsx

Upload your case list using the "Upload File" button:

Upload file

Select "Submit" to navigate to the next form where you will be able to enter person-level information for each case.

A Public Health investigator will reach out to you within 24-48 hours. Should you need immediate support, call your DSHS/DDA field manager or Public Health Call Center.

Are you willing to provide person-level details (i.e. name, date of birth etc.) for confirmed or suspected COVID-19 cases at your facility? This is optional but would help the investigation team respond more efficiently to your facility needs.

*Please note, this is NOT the appropriate form to report lab results. This information is only used for assisting in the facility investigation. To report antigen point of care test results, please open this link in a new browswer.

REDCap is HIPAA-compliant and highly secure. Any information provided here will only be shared with the investigation team following up with your facility.

Yes

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Please use this template to prepare your line list and enter as much information as you have available.

Thank you!

Attachment:Outpatient Facility Line List .xlsx

Please use this template to prepare your line list and enter as much information as you have available.

Thank you!

Attachment:Home Health Agency Line List.xlsx

Please use this template to prepare your line list and enter as much information as you have available.

Thank you!

Attachment:Workplace line list template.xlsx

If you have completed this form, please hit submit.

Contract agency email:

Contract agency phone number:

Contract agency name

Symptom onset date of first known case (if known):

M-D-Y

Are any of the positive cases contract workers?

Yes

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Number of clients (e.g. students or residents) that tested positive for COVID-19 in the past four weeks:

* must provide value

What is the total number of people who are physically at the worksite/facility at any part of the day?

Number of employees that tested positive for COVID-19 in the past four weeks:

* must provide value

Which organization are you with?

Which other outreach teams support this location?

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If other, specify:

Why are you completing this form?

* must provide value

Report case(s) of COVID-19

Report 2 or more symptomatic individuals with COVID-like illness

Report suspected transmission of COVID-19

Request technical assistance for protecting staff and clients from COVID-19

Request COVID-19 test kits

Other

Why are you completing this form?

* must provide value

Report suspected workplace transmission of COVID-19

Report suspected outbreak of COVID-19

Request technical assistance for protecting workers or clients from COVID-19

Other

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Why are you completing this form?

* must provide value

Report case(s) of COVID-19

Report 2 or more symptomatic individuals with COVID-like illness

Report suspected transmission of COVID-19

Request technical assistance for protecting staff and clients from COVID-19

Other

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Are you:

* must provide value

Organizational leadership

Staff member

Other

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If other, please describe:

Please describe the health concern(s) you have at this location:

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Are you:

* must provide value

Business owner or representative

Employee

Other

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Do the employees have close contact (less than 6 feet for more than 15 minutes) with other people (e.g., customers, co-workers, or students)?

This section asks about your business/workplace and COVID-19 concerns

If you are trying to report cases or concerns from homeless service providers or correctional facilities, please DO NOT use this form. Please report these COVID-19 cases or concerns by calling the Public Health- Seattle & King County COVID-19 call center at 206-477-3977 (open daily, 8am-10pm). The call center will be able to elevate your case to a disease investigator.

Please close window and DO NOT submit form.

If other, please specify:

If other, describe type of facility

Other, specify

If other, please describe your organization:

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