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NYC 9/11 Public Portal Document

RESPONSE GUIDELINES

2.9 Public Health Information Report Form

INSTRUCTIONS The purpose of this form is to summarize significant information about a public health episode that could be linked to contaminated water. This form should be completed by the WUERM or an individual designated by incident command. The information compiled in this form is intended to support the threat evaluation process.

In the case of a threat warning due to a report from public health, it is likely that the public health agency will assume incident command during the investigation. The drinking water utility will likely play a support role during the investigation, specifically to help determine whether or not water might be the cause.

PUBLIC HEALTH NOTIFICATION Date and Time of notification:

Name of person who received the notification:

Contact information for individual providing the notification Full Name: Title: Organization: Address: Day-time phone: Evening phone: Fax Number: E-mail address:

Why is this person contacting the drinking water utility?

Has the state or local public health agency been notified? □ Yes □ No If “No,” the appropriate public health official should be immediately notified.

DESCRIPTION OF PUBLIC HEALTH EPISODE Nature of public health episode: □ Unusual disease (mild) □ Unusual disease (severe) □ Death □ Other:

Symptoms: □ Diarrhea □ Vomiting/nausea □ Flu-like symptoms □ Fever □ Headache □ Breathing difficulty □ Other:

Describe symptoms:

Causative Agent: □ Known □ Suspected □ Unknown If known or suspected, provide additional detail below

□ Chemical □ Biological □ Radiological

Describe

Estimate of time between exposure and onset of symptoms:

27 Interim Final - August 2004

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