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Public Health Preparedness & Response

Information for Health Departments & Local Agencies

Active Disaster Surveillance Forms

When used during a disaster, these paper-based forms can be integrated into NC DETECT.

  1. North Carolina Disaster Mortality Surveillance Form (Word, 87KB / PDF, 38KB)

    Purpose: Identify the number of deaths related to the disaster and provide basic mortality information.

    Setting: Form should be filled out by medical examiners, coroners, Disaster Mortuary Operational Response Teams (DMORT), hospital, nursing home, or funeral home staff 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 designated public health official.

  2. North Carolina Disaster Morbidity Surveillance Form (Word, 76KB / PDF, 37KB)

    Purpose: To capture individual-level active surveillance of medical conditions and other disaster-related outcomes when timely, detailed, patient-level information is needed for response efforts.

    Setting: Form should be filled out by public health staff or medical personnel in acute care facilities (e.g., shelters with medical staff, special needs shelters, field hospitals, Disaster Medical Assistance Teams (DMAT)).

    How to use this form: Use the one-page form to record information about the chief complaints and specific infectious syndromes, behavioral health conditions, injuries, and chronic diseases that best describe the reason the patient is currently seeking care. One form should be filled out per patient. This form also may be filled out by abstracting information from patient records. Send completed forms to designated public health official.

  3. North Carolina Disaster Aggregate Morbidity Surveillance Form (Word, 70KB / PDF, 39KB)

    Purpose: To collect aggregate morbidity data when detailed individual-level patient information is not necessary or is too cumbersome to collect. This form serves as a summary of key disaster-related outcomes observed in a facility and can be used for monitoring population level trends.

    Setting: Form should be filled out by public health staff or medical personnel in acute care facilities (e.g., shelters with medical staff, special needs shelters, field hospitals, Disaster Medical Assistance Teams (DMAT)).

    How to use this form: Fill out the form based on individual forms or data from an existing surveillance or reporting system, or by reviewing patient logs and triage records. Send completed forms to designated public health official.

  4. North Carolina Shelter Assessment Form (Environmental Inspections of Shelters) (Word, 96KB / PDF, 55KB)

    Purpose: To standardize and record environmental assessments of shelters and evacuation centers. This form can serve as a basis for sharing timely environmental health information related to shelters and evacuation centers with local and state health officials.

    Setting: Shelters and Evacuation Centers

    How to use this form: Instructions are provided on the form for designated environmental health staff tasked with inspecting and assessing shelters and evacuation centers.