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LTC Respiratory Surveillance Line List

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SKU: 3432P

This form is designed to provide surveillance of residents and staff with respiratory illness - influenza, COVID-19, etc.  This adaptation of a CDC resource helps nursing homes and assisted living facilities detect, characterize and investigate a possible outbreak within their community.  Specific instructions are provided on the back page.

The form provides for recording the dissemination of your facility's data to your local Public Health Department when indicated/required.

Download a sample today!

  • Finished Size:  8 1/2" x 11" (11" x 17" folded)
  • Print:  4-page booklet, black ink 
  • Punching:  5-holes top and side
  • Packaging:  100 per pack

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