Type of Facility
* must provide value
Assisted Living Facility Dormitory Intermediate Care Facility Intermediate Care Facility - Individuals with Intellectual Disabilities Jail Mental Health Facility Prison Residential Care Facility Residential Summer Camp Skilled Nursing Facility Other
Please Specify "Other"* must provide value
Facility Name* must provide value
Facility Address* must provide value
Facility County* must provide value
Adair Andrew Atchison Audrain Barry Barton Bates Benton Bollinger Boone Buchanan Butler Caldwell Callaway Camden Cape Girardeau Carroll Carter Cass Cedar Chariton Christian Clark Clay Clinton Cole Cooper Crawford Dade Dallas Daviess De Kalb Dent Douglas Dunklin Franklin Gasconade Gentry Greene Grundy Harrison Henry Hickory Holt Howard Howell Iron Jackson Jasper Jefferson Johnson Knox Laclede Lafayette Lawrence Lewis Lincoln Linn Livingston Macon Madison Maries Marion McDonald Mercer Miller Mississippi Moniteau Monroe Montgomery Morgan New Madrid Newton Nodaway Oregon Osage Ozark Pemiscot Perry Pettis Phelps Pike Platte Polk Pulaski Putnam Ralls Randolph Ray Reynolds Ripley St. Charles St. Clair Ste. Genevieve St. Francois St. Louis St. Louis City Saline Schuyler Scotland Scott Shannon Shelby Stoddard Stone Sullivan Taney Texas Vernon Warren Washington Wayne Webster Worth Wright
Facility Contact Person* must provide value
Facility Contact Phone Number* must provide value
Facility Contact E-Mail* must provide value
SLCR Region* must provide value
1 2 3 4 5 6 7 ICF-IID Facility Non-LTC Facility
Date Outbreak Testing Was Completed* must provide value
Today M-D-Y
Number of Staff / Contractors / Volunteers Tested (Using POC or PCR Testing)
* must provide value
Number of Residents Tested (Using POC or PCR Testing)
* must provide value
Number of Positive Cases (Include Staff and Residents) . Please only report positive cases NOT previously reported here.
(Maximum 9 cases. Please submit additional forms to report additional cases.)
Positive Case #1: Resident or Staff Resident Staff
Positive Case #1: Date Tested Positive Today M-D-Y
Positive Case #1: Alive or Deceased Alive Deceased
Positive Case #1: Individual Remains in Facility or Transferred out of Facility In Facility Transferred out of Facility
Positive Case #1: Date of Transfer from Facility Today M-D-Y
Positive Case #1: Location of Transfer (Name & Address of Receiving Facility)
Positive Case #2: Resident or Staff Resident Staff
Positive Case #2: Date Tested Positive Today M-D-Y
Positive Case #2: Alive or Deceased Alive Deceased
Positive Case #2: Individual Remains in Facility or Transferred out of Facility In Facility Transferred out of Facility
Positive Case #2: Date of Transfer from Facility Today M-D-Y
Positive Case #2: Location of Transfer (Name & Address of Receiving Facility)
Positive Case #3: Resident or Staff Resident Staff
Positive Case #3: Date Tested Positive Today M-D-Y
Positive Case #3: Alive or Deceased Alive Deceased
Positive Case #3: Individual Remains in Facility or Transferred out of Facility In Facility Transferred out of Facility
Positive Case #3: Date of Transfer from Facility Today M-D-Y
Positive Case #3: Location of Transfer (Name & Address of Receiving Facility)
Positive Case #4: Resident or Staff Resident Staff
Positive Case #4: Date Tested Positive Today M-D-Y
Positive Case #4: Alive or Deceased Alive Deceased
Positive Case #4: Individual Remains in Facility or Transferred out of Facility In Facility Transferred out of Facility
Positive Case #4: Date of Transfer from Facility Today M-D-Y
Positive Case #4: Location of Transfer (Name & Address of Receiving Facility)
Positive Case #5: Resident or Staff Resident Staff
Positive Case #5: Date Tested Positive Today M-D-Y
Positive Case #5: Alive or Deceased Alive Deceased
Positive Case #5: Individual Remains in Facility or Transferred out of Facility In Facility Transferred out of Facility
Positive Case #5: Date of Transfer from Facility Today M-D-Y
Positive Case #5: Location of Transfer (Name & Address of Receiving Facility)
Positive Case #6: Resident or Staff Resident Staff
Positive Case #6: Date Tested Positive Today M-D-Y
Positive Case #6: Alive or Deceased Alive Deceased
Positive Case #6: Individual Remains in Facility or Transferred out of Facility In Facility Transferred out of Facility
Positive Case #6: Date of Transfer from Facility Today M-D-Y
Positive Case #6: Location of Transfer (Name & Address of Receiving Facility)
Positive Case #7: Resident or Staff Resident Staff
Positive Case #7: Date Tested Positive Today M-D-Y
Positive Case #7: Alive or Deceased Alive Deceased
Positive Case #7: Individual Remains in Facility or Transferred out of Facility In Facility Transferred out of Facility
Positive Case #7: Date of Transfer from Facility Today M-D-Y
Positive Case #7: Location of Transfer (Name & Address of Receiving Facility)
Positive Case #8: Resident or Staff Resident Staff
Positive Case #8: Date Tested Positive Today M-D-Y
Positive Case #8: Alive or Deceased Alive Deceased
Positive Case #8: Individual Remains in Facility or Transferred out of Facility In Facility Transferred out of Facility
Positive Case #8: Date of Transfer from Facility Today M-D-Y
Positive Case #8: Location of Transfer (Name & Address of Receiving Facility)
Positive Case #9: Resident or Staff Resident Staff
Positive Case #9: Date Tested Positive Today M-D-Y
Positive Case #9: Alive or Deceased Alive Deceased
Positive Case #9: Individual Remains in Facility or Transferred out of Facility In Facility Transferred out of Facility
Positive Case #9: Date of Transfer from Facility Today M-D-Y
Positive Case #9: Location of Transfer (Name & Address of Receiving Facility)
Upload Testing DocumentUpload files in Microsoft Excel format . do not upload handwritten files.do not upload files as PDF.
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