Ma 16293 2026

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270 votes

The document is a reporting form from the Massachusetts Department of Public Health for clusters of influenza and respiratory illnesses in various facilities, including long-term care and assisted living. It outlines the necessary information to be collected, such as facility demographics, illness symptoms, laboratory testing results, and control measures implemented. Facilities are encouraged to report clusters promptly to enable public health officials to respond effectively.

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Click ‘Get Form’ to open the ma 16293 in the editor.
Begin by entering the Facility Name and Report Date in the designated fields. Ensure that you format the date as mm/dd/yyyy.
Fill in the Address, City, State (ST), and ZIP code of your facility accurately.
Select the Facility Type from options such as Long Term Care or Assisted Living. If applicable, specify any other type.
Complete the Facility Contact section with a name, phone number, and email address for follow-up communications.
In the Facility Census section, provide totals for Clients and Staff, including those who are ill. Specify age groups of clients affected by illness.
Detail Cluster Information by indicating symptoms observed and vaccination percentages among clients and staff.
If lab testing has been conducted, fill out the Laboratory Information section with test types and results.
Finally, indicate which control measures have been implemented and confirm notification to your licensing agency.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (270 Votes)
2014	4.4 Satisfied (338 Votes)

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