Get Influenzalike Illness Line List For Staff Fax This Form To The Mho As Requested During An Outbreak

This guide provides clear instructions on how to correctly fill out the Influenza-Like Illness Line List for Staff. Following these steps will ensure complete and accurate submission during an outbreak, helping to maintain a safe environment for all.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the document and open it for completion.
2. Begin by entering the facility name in the designated field, followed by the telephone number.
3. Provide the contact person's name and their telephone number, ensuring accuracy for follow-up communication.
4. For each staff member, input their initials and corresponding ward or floor where they work.
5. Fill in the symptoms experienced by the staff member. Mark the relevant boxes for cough, fever, sore muscles/joints, extreme fatigue/weakness, sore throat, and any other symptoms. If there are additional symptoms, specify them in the 'Other' field.
6. Record the date of symptoms onset in the specified format (mm/dd).
7. Indicate the date of the last influenza vaccination, again using the mm/dd/yr format.
8. If the staff member was prescribed antivirals, document the date they started taking them.
9. Note the date the staff member recovered from the illness.
10. Enter the date the staff member last worked at the facility.
11. Provide the date of the staff member's next scheduled shift.
12. Answer the question regarding whether the staff member works at another facility, marking 'Yes' or 'No' as appropriate.
13. After completing all fields, review the information for accuracy, then save, download, print, or share the form as needed.

Complete your form online now to ensure timely reporting and keep everyone safe.