Line listing form 2026

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The document is a line list form for tracking cases of Influenza, Influenza-like Illness (ILI), and Upper Respiratory Illness (URI) in a healthcare facility. It includes fields for patient information, symptoms, lab testing results, and treatment details.

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Click ‘Get Form’ to open the line listing form in the editor.
Begin by entering the Facility Name at the top of the form. This identifies where the data is being collected.
In the 'Hospitalized' section, indicate whether the patient was hospitalized by selecting 'Y' for Yes or 'N' for No.
Fill in the 'Admit Date' field with the date of admission. Ensure this is accurate for proper tracking.
For each symptom listed (e.g., Myalgia, Headache, Sore throat), mark 'Y' or 'N' based on patient reports.
Record additional details such as symptom onset date and unit date in their respective fields.
Complete lab testing information by indicating if a flu test was conducted, along with results and antiviral prescriptions if applicable.

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