HURRICANE RECOVERY INFORMATION
Active Public Health Surveillance in Clinical Care Settings
Hurricane Morbidity Report Form: For Active Surveillance in Clinical Care Settings
This interim form is for individual-level active surveillance of medical conditions of public health importance after hurricanes. Clinicians should use the one-page form to record information about the chief complaints and specific infectious syndromes, mental health conditions, injuries, and chronic diseases that best describe the reason the patient is currently seeking care. This form also may be filled out by abstracting information from patient records. Complete a single form for each patient who seeks care at an acute care facility (e.g. , hospital, Disaster Medical Assistance Team).
The interim form is for use when timely, detailed, patient-level information is needed for response efforts. This information can be used to monitor the types and frequency of illnesses and injuries and to guide public health interventions. Other morbidity surveillance information sources (e.g. ,emergency room logs, aggregate tallies, syndromic surveillance) may be more appropriate when summary or less-detailed information is sufficient or when the burden of collecting detailed, individual information is substantial.
The Hurricane Morbidity Report Form is not meant to replace regular patient triage and record keeping or routine surveillance reporting mechanisms.
Individuals completing these forms should submit them to the appropriate state or local public health authorities. State or local public health authorities should modify contact information on these forms as needed for reporting within their jurisdiction. CDC is interested in receiving completed forms after they have been submitted to or reviewed by state or local agencies. The information derived through these surveillance efforts will be invaluable for identifying events of public health concern among facilities and across states. It also will assist in directing interventions and other resources to areas of greatest need.
CDC is available to support local and state surveillance efforts during a public health emergency. For questions and additional information about the "Hurricane Morbidity Report Form: For Active Surveillance in Clinical Care Settings" and supporting materials, contact the Division of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC at 1-888-422-8737 or at ehheinq@cdc.gov.
These materials will be periodically updated.
- Download PDF version of the form
(52 KB/2 pages)
- Download Word version of the form
(221 KB/2 page)
(To save the Word document to your computer, you may need to right-click on this link and select "Save Target As" or "Save Link As.")
Page last modified July 24, 2006