• Officer(s)

  • Location
  • Conducted on

  • This is a:

Demographic Data

  • Surname/Family name

  • Other names

  • Residential Street Address

  • Suburb/Town and Postcode

  • Telephone

  • Date of Birth

  • Sex

  • Aboriginal or Torres Straight Islander Origin

  • Country of Birth

  • Language Spoken at Home

  • Occupations (if child list parental occupations)

  • Name/Address of Employer or School or Child Care Attended

  • Date last attended

  • High Risk occupational group?

Treating Doctor/Hospital

  • Name of Treating Dr

  • Did the case present to hospital?

  • Name of hospital

  • Was the case admitted to hospital?

  • Date of admission

  • Date of discharge/death

Illness (Summary)

  • First symptom

  • Onset date of first symptom

  • Time of onset of first symptom

  • Maximum stools in 24 hours

  • Duration of diarrhoea (days/hours)

  • Total duration of illness (days)

  • History of Illness:

  • Was the case given antibiotics to treat the illness?

  • If yes, what antibiotics?

  • Is the case still taking antibiotics?

  • What date did the case last take antibiotics?

Contact Data

  • In the week prior to the onset of illness, has the case:

  • Had contact with a family member with a similar illness?

  • Had contact with a friend or work/school colleague with a similar illness?

  • If yes to the above questions, detail name, age, relationship, address, phone number, occupation/child care/school, onset date and if a faeces culture has been taken.

  • Could illness in the case be linked to illness in any others

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.