Transcription of Influenza-like Ilnness (ILI) Line List for Long-Term …
1 Influenza-like illness (ILI) line List Facility _____ For Long-Term care facilities Use this 2-page form to collect data. Complete both pages for each resident with ILI. Dates _____ Lab Results Vaccine Status (date) Symptoms (Y/N/U) ILI Other Name Room No. Age Sex (M/F) influenza pneumococcal Onset Date of ILI Symptoms Duration (days) Highest Temp myalgia headache sore throat cough chills coryza other viral culture rapid test H1N1 (commercial lab) H1N1 (MDH lab) viral culture bacterial culture 1. 2.
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3 16. 17. 18. 19. 20. Minnesota Department of Health Vaccine Preventable Diseases Page 1 of 2 Influenza-like illness (ILI) line List for Long-Term care facilities continued Vaccine Preventable Diseases Box 64975 St. Paul, MN 55164-0975 Page 2 of 2 Facility _____ Dates _____ Antivirals Pneumonia Hospitalized Died zanamivir oseltamivir amantadine rimantadine Name (from previous page) Physicial diagnosed x-ray confirmed Y/N admission date Y/N Y/N date started Y/N date started Y/N date started Y/N date started 1.
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