Facility Name* must provide value
Facility Street Address* must provide value
Facility City* must provide value
Facility State* must provide value
Facility Zip Code* must provide value
Facility Phone Number* must provide value
ten-digit U.S. phone number
Point of Contact - Name* must provide value
Point of Contact - Role at Facility* must provide value
Point of Contact - Direct Phone Number* must provide value
ten-digit U.S. phone number
Point of Contact - Phone Extension
Point of Contact - Email Address* must provide value
What type of facility/site are you reporting for? Please review all categories and choose the best fit.* must provide value
Skilled Nursing Facility (SNF)
Non-SNF licensed and unlicensed caregiving facilities (AL, ALF, RCFE, ARF, ICF, CLHF)
Short-Term Residential Therapeutic Programs (STRTP) or Transitional Shelter Care Program Facilities (TSCF)
Other residential caregiving facilities including Residential Substance Use, Sober Living, ODR, Adult Day Camp
Residential non-caregiving facilities including boarding homes and Project 180
Outpatient Facilities or Dialysis Centers (including home health, dental, veterinary and physical therapy offices)
Acute Care Hospitals, Acute Psychiatric Hospitals, Sub-acute, D/P SNFs, and LTC licensed by hospitals
Places of Worship, Recreation and Gym/Fitness
Education (college and university, trade school, K-12 schools, early childhood education, family childcare, preschool, afterschool program, camp, parks and rec, daycare, youth sports)
Persons Experiencing Homelessness (shelter, agency providing housing or services for PEH, PRK Sites, SRO, Project Homekey, and Project Safe Haven)
First Responders (EMS, Fire and Private Ambulance Providers)
Law Enforcement and Courts (police/sheriff stations, highway patrol, courthouses)
Correctional Facilities (jails, prisons, juvenile probation)
Food facilities (restaurants, take out, bars, grocery stores, any facility that sells, processes or ships food)
Work sites (businesses including but not limited to manufacturing, storage, transport, distribution and/or retail of non-food items, offices, construction, media, and service providers including government, auto, hotels, banks)
Ticketed and non-Ticketed Transit (airplanes, trains, buses and ships)
Professional Sports Teams
Other - PLEASE CONFIRM YOUR FACILITY DOES NOT FIT IN ONE OF THE ABOVE CATEGORIES
Describe Type of Facility:
Other Facility/Site - Please Describe* must provide value
Education (select best description):* must provide value
Institute for Higher Education K-12 school Early Childhood Education K-12 School - Day Care for School Aged Children Non K-12 School - Day Care for School Aged Children Parks and Recreation Camp K-12 School - Youth Sports Program Non K-12 School - Youth Sports Program Other
This report is for cases at:
Campus District Office
Persons Experiencing Homelessness (select best description):* must provide value
Shelter Agency providing housing or services for PEH PRK site SRO Project Homekey Project Safe Haven Other
Non-SNF Licensed Caregiving Facility (select best description):* must provide value
Assisted Living (AL or ALF) Long Term Care Facility (LTC or LTCF) Residential Care Facility for the Elderly (RCFE) Adult Residential Facility (ARF) Intermediate Care Facility (ICF) Congregate Living Health Facility (CLHF) Other
Does this facility provide caregiving services primarily to residents with at least two or more of the following:
Yes No
Outpatient Facilities or Dialysis Centers (select best description):* must provide value
Outpatient Ambulatory Clinics (primary care, specialty care, etc.) Dialysis Centers Urgent Cares Surgery Centers Home Health Agencies/Hospice/In-home care for seniors and disabled Dental Clinics Veterinary Clinics/Hospitals Physical/Occupational Therapy Mental Health Counseling non-residential centers/Substance Abuse Counseling Centers Other
Estimated Number of Total Persons Onsite at Facility * must provide value
Is this report an update to a previous recent report of cases?* must provide value
Yes No
If available, please enter the report/reference number from your original report(s).
Number of Additional Confirmed COVID-19 Cases* must provide value
Total Number of Confirmed COVID-19 Cases within a 14 Day period (both from previous and current report)* must provide value
Number of Confirmed COVID-19 Cases (within a 14 day period)* must provide value
Number of Total Confirmed COVID-19 Cases that are Staff/Employees/Volunteers
Number of Total Confirmed COVID-19 Cases that are Patient/Resident/Student/Client
Qualifies for Cases Report (Confirmed Cases)
View equation
Total Cases (Confirmed for new report, Total for updated report)
View equation
Qualifies for Cases Report (< 5 cases)
View equation
Qualifies for Cases Report (>=3 for facilities = work sites, food facilities, residential non-caregiving, transit, professional sports, places of worship)
View equation
Qualifies for Cases Report
View equation
You've indicated that there are ______ confirmed COVID-19 cases (within a 14 day period) at this facility. Based on the facility/site type you selected, this does not qualify as a reportable cluster since you have not met the reporting criteria of 3 cases in a 14 day period. not , please correct in the fields above. this is correct , please mark yes and submit below. If you have 3 or more cases in a 14 day period please submit a new report.* must provide value
Yes, the information is correct and I understand that this does not qualify as a reportable cluster. I will submit a new report if there are 3 or more cases in 14 days.
You've indicated that there are ______ confirmed COVID-19 cases (within a 14 day period) at this facility. Based on the facility/site type you selected, this does not qualify as a reportable cluster since you have not met the reporting criteria of 3 cases in a 14 day period. not , please correct in the fields above. this is correct , please mark yes and submit below. If you have 3 or more cases in a 14 day period please submit a new report.* must provide value
Yes, the information is correct and I understand that this does not qualify as a reportable cluster. I will submit a new report if there are 3 or more cases in 14 days.
Number of Symptomatic People Not Tested or Results Pending (PUI)
How do the cases interact at work? Do they work in the same area/department? Are they on the same shift? Are there common spaces where the cases may have been together?
Are any of the cases from the same household? Yes No
Do any of the cases carpool?
Yes No
Is the carpool employer provided transport?
Yes No
You've indicated that there are ______ confirmed COVID-19 cases (within a 14 day period) at this facility. * must provide value
Confirming that there are five (5) or more cases at this facility.
Since you have 5 or more cases at your facility, please complete the line list here with details for each of your COVID cases. You can use the line list to track your cases.
(To open the line list in Chrome, please right click and select 'Open link in new tab.' For other browsers, clicking on the link directly should open the line list.)
Click 'Submit' below to complete your report and receive a reference number for your submitted report.
Since you have 5 or more cases at your facility, please complete the line list here with details for each of your COVID cases. You can use the line list to track your cases.
(To open the line list in Chrome, please right click and select 'Open link in new tab.' For other browsers, clicking on the link directly should open the line list.)
Click 'Submit' below to complete your report and receive a reference number for your submitted report.
Thank you for providing this information. Please note: To meet Los Angeles County Department of Public Health reporting requirements, facilities are required to fill out a line list with all laboratory-confirmed cases and close contacts. If you have not done so already, please submit a line list to ACDC-Education@ph.lacounty.gov http://publichealth.lacounty.gov/acd/Diseases/EpiForms/COVID_OBlinelist_Education_Sector.xlsx ACDC-Education@ph.lacounty.gov with any questions about submitting the line list.
Click 'Submit' below to complete this report and receive a reference number.
Since you have 5 or more cases at your facility, please complete the line list here with details for each of your COVID cases. You can use the line list to track your cases.
(To open the line list in Chrome, please right click and select 'Open link in new tab.' For other browsers, clicking on the link directly should open the line list.)
Click 'Submit' below to complete your report and receive a reference number for your submitted report.
Since you have 5 or more cases at your facility, please complete the line list here with details for each of your COVID cases. You can use the line list to track your cases.
(To open the line list in Chrome, please right click and select 'Open link in new tab.' For other browsers, clicking on the link directly should open the line list.)
Click 'Submit' below to complete your report and receive a reference number for your submitted report.
Case 1 - First Name
Case 1 - Last Name
Case 1 - Date of Birth M-D-Y MM-DD-YYYY
Case 1 - Status
Staff/Employee/Volunteer Patient/Resident/Student/Client
Case 1 - Job Function/Title
Case 1 - Does this person have direct contact with residents?
Yes No
Case 1 - Type of Exposure? Household contacts Community Travel Worksite/facility Other
Case 1 - Date of Admission Today M-D-Y MM-DD-YYYY
Case 1 - Was the patient at the facility for at least 14 days before test date?
Yes No
Case 1 - Date of Symptom Onset Today M-D-Y MM-DD-YYYY
Case 1 - Date of Test Today M-D-Y MM-DD-YYYY
Case 1 - Last Day at Facility Today M-D-Y MM-DD-YYYY
Case 1 - Date Notified of Positive Results Today M-D-Y MM-DD-YYYY
Case 2 - First Name
Case 2 - Last Name
Case 2 - Date of Birth M-D-Y MM-DD-YYYY
Case 2 - Status
Staff/Employee/Volunteer Patient/Resident/Student/Client
Case 2 - Job Function/Title
Case 2 - Does this person have direct contact with residents?
Yes No
Case 2 - Type of Exposure? Household contacts Community Travel Worksite/facility Other
Case 2 - Date of Admission Today M-D-Y MM-DD-YYYY
Case 2 - Was the patient at the facility for at least 14 days before test date?
Yes No
Case 2 - Date of Symptom Onset Today M-D-Y MM-DD-YYYY
Case 2 - Date of Test Today M-D-Y MM-DD-YYYY
Case 2 - Last Day at Facility Today M-D-Y MM-DD-YYYY
Case 2 - Date Notified of Positive Results Today M-D-Y MM-DD-YYYY
Case 3 - First Name
Case 3 - Last Name
Case 3 - Date of Birth M-D-Y MM-DD-YYYY
Case 3 - Status
Staff/Employee/Volunteer Patient/Resident/Student/Client
Case 3 - Job Function/Title
Case 3 - Does this person have direct contact with residents?
Yes No
Case 3 - Type of Exposure? Household contacts Community Travel Worksite/facility Other
Case 3 - Date of Admission Today M-D-Y MM-DD-YYYY
Case 3 - Was the patient at the facility for at least 14 days before test date?
Yes No
Case 3 - Date of Symptom Onset Today M-D-Y MM-DD-YYYY
Case 3 - Date of Test Today M-D-Y MM-DD-YYYY
Case 3 - Last Day at Facility Today M-D-Y MM-DD-YYYY
Case 3 - Date Notified of Positive Results Today M-D-Y MM-DD-YYYY
Case 4 - First Name
Case 4 - Last Name
Case 4 - Date of Birth M-D-Y MM-DD-YYYY
Case 4 - Status
Staff/Employee/Volunteer Patient/Resident/Student/Client
Case 4 - Job Function/Title
Case 4 - Does this person have direct contact with residents?
Yes No
Case 4 - Type of Exposure? Household contacts Community Travel Worksite/facility Other
Case 4 - Date of Admission Today M-D-Y MM-DD-YYYY
Case 4 - Was the patient at the facility for at least 14 days before test date?
Yes No
Case 4 - Date of Symptom Onset Today M-D-Y MM-DD-YYYY
Case 4 - Date of Test Today M-D-Y MM-DD-YYYY
Case 4 - Last Day at Facility Today M-D-Y MM-DD-YYYY
Case 4 - Date Notified of Positive Results Today M-D-Y MM-DD-YYYY
PUI 1 - First Name
PUI 1 - Last Name
PUI 1 - Date of Birth M-D-Y MM-DD-YYYY
PUI 1 - Status
Staff/Employee/Volunteer Patient/Resident/Student/Client
PUI 1 - Job Function/Title
PUI 1 - Date of Admission Today M-D-Y MM-DD-YYYY
PUI 1 - Was the patient at the facility for at least 14 days before test date?
Yes No
PUI 1 - Date of Symptom Onset Today M-D-Y MM-DD-YYYY
PUI 1 - Has the symptomatic person been tested?
Yes No
PUI 1 - Date of Test Today M-D-Y MM-DD-YYYY
PUI 2 - First Name
PUI 2 - Last Name
PUI 2 - Date of Birth M-D-Y MM-DD-YYYY
PUI 2 - Status
Staff/Employee/Volunteer Patient/Resident/Student/Client
PUI 2 - Job Function/Title
PUI 2 - Date of Admission Today M-D-Y MM-DD-YYYY
PUI 2 - Was the patient at the facility for at least 14 days before test date?
Yes No
PUI 2 - Date of Symptom Onset Today M-D-Y MM-DD-YYYY
PUI 2 - Has the symptomatic person been tested?
Yes No
PUI 2 - Date of Test Today M-D-Y MM-DD-YYYY
Updated Facility Type Skilled Nursing Facility (SNF) Non-SNF licensed and unlicensed caregiving facilities (AL, ALF, RCFE, ARF, ICF, CLHF) Short-Term Residential Therapeutic Programs (STRTP) or Transitional Shelter Care Program Facilities (TSCF) Other residential caregiving facilities including Drug Rehab Centers, Sober Living, ODR Residential non-caregiving facilities including boarding homes and Project 180 Outpatient Facilities or Dialysis Centers (including home health, dental, veterinary and physical therapy offices) Acute Care Hospitals, Acute Psychiatric Hospitals, Sub-acute, D/P SNFs, and LTC licensed by hospitals Places of Worship, Recreation and Gym/Fitness Education (college and university, K-12 Schools, Early Childhood Education, preschool, afterschool program, camp, parks and rec, daycare, youth sports) Persons Experiencing Homelessness (shelter, agency providing housing or services for PEH, PRK Sites, SRO, Project Homekey, and Project Safe Haven) First Responders (EMS, Fire and Private Ambulance Providers) Law Enforcement and Courts (police/sheriff stations, highway patrol, courthouses) Correctional Facilities (jails, prisons, juvenile probation) Food facilities (restaurants, take out, bars, grocery stores, any facility that sells, processes or ships food) Work sites (businesses including but not limited to manufacturing, storage, distribution and/or retail of non-food items, offices, service providers, construction, hotels, and media) Ticketed and non-Ticketed Transit (airplanes, trains, buses and ships) Professional Sports Teams Other
Update if selected facility type was 'Other' or incorrect
Submit
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