If you experience technical difficulties with this website, please call the LAC Communicable Disease Reporting line at 888-397-3993 (press option 5) to report. Reporting should only be done during business hours (Monday through Friday, 8:00am-5:00pm) unless there is an urgent question about the report. Survey Start Now M-D-Y H:M:S
Survey Timestamp for Use
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
6-Digit NAICS Code for Facility
Please locate the code that best describes your industry at https://www.census.gov/naics/ by entering a key word into the 2017 NAICS search box. Entering detailed key words will narrow list of options. Choose the code that is most appropriate.
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)
Acute Care Hospitals, Acute Psychiatric Hospitals, Sub-acute, D/P SNFs, and Long Term Acute Care Hospitals
Non-SNF licensed and unlicensed caregiving facilities (AL, ALF, RCFE, ARF, ICF, CLHF, CBAS)
Short-Term Residential Therapeutic Programs (STRTP) or Transitional Shelter Care Program Facilities (TSCF) and Community Treatment Centers (CTC)
Other residential caregiving facilities including Residential Substance Use, Sober Living, ODR, Adult Day Program
Residential non-caregiving facilities including boarding homes and Project 180
Outpatient Facilities or Outpatient Ambulatory Dialysis Centers (including home health, dental, and physical therapy offices)
Places of Worship, Recreation and Gym/Fitness
Places of Worship or Civic Organization
Fitness and Gym Facilities
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)
Restaurants
Non-Restaurant Food Facilities (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, veterinary offices)
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:
Check all that apply to your facility:
Facility is a manufacturing site
Facility is a warehousing and storage site
Facility provides social assistance or public services directly to clients or customers
Less than 70% of your workforce is known to be fully vaccinated
Facility has experienced a prior worksite outbreak as determined by LAC DPH
Check all that apply to your facility:
Facility offers classes to children
Facility has experienced a previous worksite outbreak as determined by LAC DPH
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) Community Based Adult Services (CBAS) Other
Does your facility provide any of the following caregiving services primarily to residents in these categories? (Please select all that apply)
Residents older than 65 years of age
A memory care unit or at least 25% residents with dementia or severe mental illness diagnosis
Medical care to residents who are non-ambulatory
Serve residents that require regular direct on-site medical care
None of the above
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 the facility/site located within Los Angeles County?
Yes - facility/site is located in Los Angeles County
No - facility/site is not located in Los Angeles County
Facilities/sites located in counties outside of Los Angeles County do not need to report suspected outbreaks to Los Angeles County DPH. LAC DPH recommends that you notify the local health jurisdiction of the facility/site. To report laboratory test results, see LA County DPH's Guidelines for Provider and Laboratory Reporting .
Confirming that facility/site is not located in Los Angeles County
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
Total Number of Probable/Suspect COVID-19 Cases within a 14 day period (both from previous and current report) that are Staff/Employee/Volunteers
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 Staff/Employees/Volunteers with a positive PCR test
Number of Total Staff/Employees/Volunteers with a positive antigen/point of care test
*If an individual has both a positive PCR result and a positive antigen/point of care test result, please only count the individual once in the positive PCR category
Number of Probable/Suspect COVID-19 Cases (within a 14 day period) that are Staff/Employee/Volunteers
Number of Total Confirmed COVID-19 Cases that are Patient/Resident/Student/Client
Number of Total Patient/Resident/Student/Client with a positive PCR test
Number of Patient/Resident/Student/Client cases with a positive PCR who have been at the facility for 7 days or more
Number of Total Patient/Resident/Student/Client with a positive antigen/point of care test
*If an individual has both a positive PCR result and a positive antigen/point of care test result, please only count the individual once in the positive PCR category
Number of Patient/Resident/Student/Client cases with a positive antigen/point of care test who have been at the facility for 7 days or more
Qualifies for Cases Report (Confirmed Cases)
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Total Cases (Confirmed for new report, Total for updated report)
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Qualifies for Cases Report (< 5 cases)
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Qualifies for Cases Report (>=3 for facilities = work sites, food facilities, residential non-caregiving, professional sports, places of worship)
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Qualifies for Cases Report
View equation
Attack Rate (Worksites, Rec & Gym, Non-Restaurant Food)
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?
How do the cases interact at work? Are there common spaces where the cases may have been together?
Have any of the cases been identified as close contacts to each other?
For definition of "close contact", refer to this guidance .
Yes No
Do at least two cases work in the same area/department/shift? Yes No
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
Please provide any additional information regarding exposures the cases may have had to COVID-19 while at work or outside of work, if applicable.
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 window.' 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 of each of your COVID cases as soon as possible and no later than one business day from the time of this report.
(To open the line list in Chrome, please right click and select 'Open link in new window.' For other browsers, clicking on the link directly should open the line list.)
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 window.' 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.
To report education cases or contacts please use the Shared Portal for Outbreak Tracking (SPOT) TK-12 schools, Institutes of Higher Education and Early Childhood Education (ECE) providers are required to notify the LAC DPH of staff and students/children with confirmed COVID-19 within 1 business day. Sites only need to report confirmed cases who were on campus at any point within the 14 days prior to their illness onset date. The illness onset date is the first date of COVID-19 symptoms or the COVID-19 test date, whichever is earlier. Schools may also report persons on campus who were exposed to the infected person during the infectious period. Please contact acdc-education@ph.lacounty.gov with any questions.
Confirming the report is for an Education setting
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 window.' 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 window.' 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.
Healthcare providers/clinical facilities conducting CLIA-waived testing at the point of care setting are required to report all positive SARS-CoV-2 test results. All Long Term Care Facilities should use the Long Term Care Facility COVID-19 Point of Care Test Result Report Form to report all positive SARS-CoV-2 POCT results to Public Health.
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
Click 'Submit' below to complete your report and receive a reference number for your submitted report.
Please review and implement recommendations from DPH.
Updated Facility Type Skilled Nursing Facility (SNF) Acute Care Hospitals, Acute Psychiatric Hospitals, Sub-acute, D/P SNFs, and Long Term Acute Care Hospitals 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) and Community Treatment Centers (CTC) 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, and physical therapy offices) Places of Worship or Civic Organization Fitness and Gym Facilities 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) Restaurants Non-Restaurant Food Facilities (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, veterinary offices) Ticketed and non-Ticketed Transit (airplanes, trains, buses and ships) Professional Sports Teams Other Duplicate Record Non-COVID Report
Update if selected facility type was 'Other' or incorrect
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