Get Ma 16293 2019-2025

The MA 16293 is an important form used for reporting clusters of influenza and respiratory illness in various facilities. This guide will provide clear and concise steps to assist users in completing the form accurately and efficiently online.

Follow the steps to fill out the MA 16293 form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the name of the facility in the 'Facility Name' field. This is essential for identifying the reporting institution.
3. Input the report date in the designated field using the format mm/dd/yyyy.
4. Fill out the address fields including 'Address', 'City', 'State', and 'ZIP Code' to provide the location of the facility.
5. Select the facility type from options such as 'Long Term Care', 'Assisted Living', or another category if applicable.
6. Provide the contact information for the facility, including 'Facility Contact', 'Phone', and 'Email'.
7. Complete the facility census section by entering the total number of clients and staff, as well as the number of ill clients and staff.
8. In the 'Cluster Information' section, indicate the age group of clients and the percent vaccinated against influenza.
9. Document any observed symptoms in the respective section and include the dates of the first and latest onset.
10. In the laboratory information section, state if lab testing has been conducted and specify the type of testing done.
11. Outline the control measures that have been implemented regarding the outbreak.
12. Finally, ensure you have notified the appropriate licensing agency and provided the date of notification.
13. After completing the form, save changes, download, print, or share the form as needed.

Complete the MA 16293 form online to ensure prompt reporting of health concerns.