GASTROENTERITIS LINE LIST FORM

Facility Name_________________________________
Contact Person_________________Email______________

Abdominal Cramps Y/N/U

Vomiting Y/N/U

Pt. Location Nausea Y/N/U Fever Y/N/U

Severity
Hospital Name (if hosp) Date of Death Hospitalized Y/N/U Physician Seen Y/N/U Died Y/N/U

Treatment
Antidiarrheal Medication Y/N/U Antibiotic Y/N/U

Lab Testing Lab Name(if testing done)____________

Specimen Type

Case Room initials Unit #

Y/N/U

Symptom onset date

Diarrhea Y/N/U

T max

Duration

Collect Date

Type of test

Result

BCDC GI Illness Line List Form March 2004 DRAFT

*ND = not done