At a glance
The forms below can be used to conduct disaster-related morbidity and mortality surveillance. Please note that these forms are not meant to replace normal patient triage and record keeping or routine surveillance reporting mechanisms.
Morbidity Surveillance
Note
Natural Disaster Morbidity Surveillance Individual Form (Interim)
Purpose: To capture individual-level active surveillance of medical conditions when timely, detailed, patient-level information is needed for response efforts.
Setting: Acute care facilities (e.g., shelters with medical staff, hospitals)
How to use this form: Use this form to record information about the main complaints and specific infectious diseases, mental health conditions, injuries, and chronic diseases that best describe why the patient is currently seeking care. Fill out one form per patient. This form may also be completed by abstracting information from patient records.
Natural Disaster Morbidity Surveillance Individual Form (Interim)
Natural Disaster Morbidity Surveillance Individual Form (Interim)
Natural Disaster Morbidity Surveillance Line List (Interim)
Purpose: This form is an abbreviated version of the Natural Disaster Morbidity Report Form. Use this form if summary or less-detailed information is sufficient or when the burden of collecting detailed, individual information is substantial.
Setting: Hospitals
How to use this form: Fill out one row per patient. You can also fill out the form by abstracting information from patient records.
Natural Disaster Morbidity Surveillance Line List (Interim)
Natural Disaster Morbidity Surveillance Line List (Interim)
Note: Persons with disabilities having problems accessing the Excel spreadsheet may call 1-800-CDC-INFO (1-800-232-4636) for assistance.
Natural Disaster Morbidity Surveillance Tally Sheet (Interim)
Purpose: This form is an abbreviated version of the Natural Disaster Morbidity Report Form. Use this form if summary or less-detailed information is sufficient and a tally sheet is the most useful way to capture morbidity data. This form captures morbidity data at the individual level, but it does not separate data by individual.
Setting: Shelter facilities
How to use this form: Use one form per facility per reporting period (e.g., 8, 12, 24 hour). Place a tally mark next to each injury/illness that a patient reports.
Natural Disaster Morbidity Surveillance Tally Sheet (Interim)
Natural Disaster Morbidity Surveillance Summary Report Form (Interim)
Purpose: To collect aggregate morbidity data. Use this form for reporting purposes. It does not capture individual-level data.
Setting: Acute care facilities (e.g., shelters with medical staff, hospitals)
How to use this form: Fill out the form based on individual forms or data from an existing surveillance or reporting system.
Natural Disaster Morbidity Surveillance Summary Report Form (Interim)
Natural Disaster Morbidity Surveillance Summary Report Form (Interim)
Mortality Surveillance
Disaster-Related Mortality Surveillance Form
Note
Purpose: Identify the number of deaths related to the disaster and provide basic mortality information.
Setting: This form should be filled out by medical examiners, coroners, hospitals, nursing homes, or funeral homes during a disaster. This form does not replace the death certificate.
How to use this form: Use this form for all known deaths related to the disaster. Complete one form per decedent. Send completed forms to the designated public health official. EPI INFO databases are available upon request.
Disaster-Related Mortality Surveillance Form
General Instructions for Completing the Disaster-Related Mortality Surveillance Form
Disaster-Related Mortality Surveillance Form (Spanish)
General Instructions for Completing the Disaster-Related Mortality Surveillance Form (Spanish)