Form CDS-38 "Outbreak Report for Child Care, School and Camp Settings" - New Jersey

What Is Form CDS-38?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2015;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CDS-38 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form CDS-38 "Outbreak Report for Child Care, School and Camp Settings" - New Jersey

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New Jersey Department of Health
Communicable Disease Service
OUTBREAK REPORT FOR CHILD CARE, SCHOOL AND CAMP SETTINGS
Name of Lead Public Health Agency
County
E#
Date Outbreak Reported to Local Health Department (LHD):
Date Reported to State Health Department
BRIEF SUMMARY
Summary should include key facts that describe what happened. Some information to include: date and place of outbreak, key
statistics (number exposed, number of cases, number hospitalized, number of deaths, average duration of illness), causative or
suspect organism, control measures and recommendations.
FACILITY INFORMATION
A. FACILITY DESCRIPTION
Name of Facility
Telephone Number
Street Address
County
City/Town
Zip Code
Name of Contact Person
Contact Telephone Number
CDS-38
AUG 15
Page 1 of 4 Pages.
New Jersey Department of Health
Communicable Disease Service
OUTBREAK REPORT FOR CHILD CARE, SCHOOL AND CAMP SETTINGS
Name of Lead Public Health Agency
County
E#
Date Outbreak Reported to Local Health Department (LHD):
Date Reported to State Health Department
BRIEF SUMMARY
Summary should include key facts that describe what happened. Some information to include: date and place of outbreak, key
statistics (number exposed, number of cases, number hospitalized, number of deaths, average duration of illness), causative or
suspect organism, control measures and recommendations.
FACILITY INFORMATION
A. FACILITY DESCRIPTION
Name of Facility
Telephone Number
Street Address
County
City/Town
Zip Code
Name of Contact Person
Contact Telephone Number
CDS-38
AUG 15
Page 1 of 4 Pages.
OUTBREAK REPORT FOR CHILD CARE, SCHOOL AND CAMP SETTINGS
(Continued)
FACILITY INFORMATION
A. FACILITY DESCRIPTION
Type of Facility/Population (check all that apply):
Total Number of:
College/University
Students:
Child Care
Pre-School
Day Camp
Children:
School/Grade Levels
Residential Camp
Staff:
State the number of buildings, wings, units, cabins, floors, etc. that make up the facility. Include number and describe population per
area (e.g., age group, grade, student, staff, etc.).
B. OUTBREAK DEMOGRAPHICS
Total Number (Census):
# Ill:
# Hospitalized:
# Visited ER:
# Visited HCP:
# Deaths:
Students:
Total Number:
# Ill:
# Hospitalized:
# Visited ER:
# Visited HCP:
# Deaths:
Staff: *
* Staff includes volunteers, teachers, counselors, housekeeping, recreational, cafeteria, health and administrative activities.
%
%
Female:
Gender (estimated percent of the primary cases):
Male:
Specify location of outbreak within physical structure described above. If requested, Attach floor plan and identify affected area(s):
Illness Onset Date – FIRST Case
Illness Onset Date – LAST Case
Incubation Period
Duration of Illness (e.g., 24-48 hours, 1-5 days)
Shortest
Minutes
Hours
Days
Shortest
Minutes
Hours
Days
Median
Minutes
Hours
Days
Median
Minutes
Hours
Days
Longest
Minutes
Hours
Days
Longest
Minutes
Hours
Days
Total Number of Cases for Whom Information is Available:
Total Number of Cases for Whom Information is Available:
Unknown Incubation Period
Unknown Duration of Illness
Type of Illness
GI
Respiratory/ILI
Influenza
Rash Illness (specify if known):
Other (specify):
CDS-38
AUG 15
Page 2 of 4 Pages.
OUTBREAK REPORT FOR CHILD CARE, SCHOOL AND CAMP SETTINGS
(Continued)
B. OUTBREAK DEMOGRAPHICS
Signs and Symptoms (check all that apply and document % of cases for each):
X
%
Sign or Symptom
X
%
Sign or Symptom
X
%
Sign or Symptom
Abdominal cramps
Fatigue
Nausea
Bloody stool
Fever
Rash
Chills
Headache
Sore throat
Cough
HUS
Vomiting
Diarrhea
Nasal Congestion
Other (Specify):
OUTBREAK INVESTIGATION
A. INVESTIGATION TEAM
Representative’s Position
Name/Title
Telephone Number
Facility
Local Health
NJDOH
Other (Specify)
B. OUTBREAK CASE DEFINITION
C. MODE OF TRANSMISSION
Foodborne
Person to Person
Waterborne
No Source Identified
Other (specify):
D. LABORATORY TESTING
Number of Specimens Tested
Number of Specimens Tested Positive
No Specimens Obtained
CDS-38
AUG 15
Page 3 of 4 Pages.
OUTBREAK REPORT FOR CHILD CARE, SCHOOL AND CAMP SETTINGS
(Continued)
D. LABORATORY TESTING
Agent(s) Detected:
E. CONSULTATION/INVESTIGATION: TYPE AND FINDINGS
Health Officer: On-site evaluation?
No
Yes
Name:
Public Health Nurse: On-site evaluation?
No
Yes
Name:
Registered Environmental Health Specialist: On-site evaluation?
No
Yes
If Yes, please attach report.
Name:
Other (Specify):
CONTROL MEASURES
Refer to control measures section of outbreak guidance document http://www.nj.gov/health/cd/outbreaks.shtml. Complete
and attach section to this report.
DOCUMENTATION
Documents Attached to this Outbreak Summary (check all that apply):
Epidemic Curve
Line-Listing (required)
REHS Facility Inspection Report
Floor Plan
Lab Test Reports (required if available)
Foodborne Outbreak Summary Form
Waterborne Outbreak Summary Form
Control Measures (required)
Other (specify):
OUTCOME
Date Outbreak Resolved (i.e., control measures lifted):
Recommendations for Future Actions
Other (Please describe):
Adhere to Timely Reporting
Revise Protocol
Develop New Protocol
Change Product Use
Reinforce Exclusion
COMPLETED BY
Name:
Title:
Agency:
Phone:
Fax:
Email:
CDS-38
AUG 15
Page 4 of 4 Pages.
Page of 4