The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

serX3ejSLCVNZqnbfE4sAmwMCwRWf6

COVID-19 Outbreak and Death Reporting Form for Shelters and Correctional Facilities

Please use this form to report:

Any outbreak or unusual cluster of COVID-19 cases
Death in a staff person or resident suspected to have died due to COVID-19

Correctional facilities and shelters operating under a CLIA waiver must report all positive, facility-administered rapid tests (e.g. Binax, Cue, QuickVue, etc.) through the SimpleReport system.

Test reporting resources:

If you would like technical asssistance from MDH, please contact Health.R-congregate@state.mn.us.

Name of Congregate Living Facility

* must provide value

Facility Address

* must provide value

Name of Person Submitting this Report

* must provide value

Email of Person Submitting this Report

* must provide value

Phone of Person Submitting this Report

What are you reporting?

* must provide value

Individual case information (maximum 3 cases)

Uploading a spreadsheet with case information

Reporting an outbreak or unusual situation

Reporting a COVID-19 related death

reset

What are you reporting?

* must provide value

Reporting an outbreak or unusual situation

Reporting a COVID-19 related death

reset

To upload a spreadsheet of cases, please download the attached template and make sure that it contains the following information:
- First name of Case
- Last name of Case
- Date of Birth of the Case
- Date of the positive COVID-19 test
- Type of test used
- Case Type (staff or resident)

Attachment:MDH Reporting Spreadsheet for Congregate Living Facilities_Template.xlsx

Upload a Reporting Spreadsheet

* must provide value

Upload file

Patient 1: First Name

* must provide value

Patient 1: Last Name

* must provide value

Patient 1: Date of Birth

* must provide value

M-D-Y

Patient 1: Date of Birth Unknown?

Yes

reset

Patient 1: Case type

* must provide value

Resident

Staff

reset

Patient 1: Date of Positive Test

* must provide value

M-D-Y

Patient 1: Type of Test Used

* must provide value

Patient took their own test and told us the result

Patient took a test at a lab or clinic and told us the result

I don't know

reset

Patient 1: Self-reported Race

American Indian Alaskan Native

Asian

Black African American

Native Hawaiian Pacific Islander

White

Other

Unknown

Refused to answer

Patient 1: Is this an out of state case?

Yes

reset

Patient 2: First Name

Patient 2: Last Name

Patient 2: Date of Birth

M-D-Y

Patient 2: Date of Birth unknown?

Yes

reset

Patient 2: Case Type

Resident

Staff

reset

Patient 2: Date of Positive Test

M-D-Y

Patient 2: Type of Test Used

Patient took their own test and told us the result

Patient took a test at a lab or clinic and told us the result

I don't know

reset

Patient 2: Self-reported Race

American Indian Alaskan Native

Asian

Black African American

Native Hawaiian Pacific Islander

White

Other

Unknown

Refused to answer

Patient 2: Is this an out of state case?

Yes

reset

Patient 3: First Name

Patient 3: Last Name

Patient 3: Date of Birth

M-D-Y

Patient 3: Date of Birth unknown?

Yes

reset

Patient 3: Case Type

Resident

Staff

reset

Patient 3: Date of Positive Test

M-D-Y

Patient 3: Type of Test Used

Patient took their own test and told us the result

Patient took a test at a lab or clinic and told us the result

I don't know

reset

Patient 3: Self-reported Race

American Indian Alaskan Native

Asian

Black African American

Native Hawaiian Pacific Islander

White

Other

Unknown

Refused to answer

Patient 3: Is this an out of state case?

Yes

reset

Tell us about your situation:

* must provide value

Expand

First name of the patient that died

* must provide value

Last name of the patient that died

* must provide value

Date of birth of the patient that died

* must provide value

M-D-Y

Case type of the patient that died

* must provide value

Resident

Staff

reset

Date of positive test of the patient that died

* must provide value

M-D-Y

Type of test of the patient that died

* must provide value

Patient took their own test and told us the result

Patient took a test at a lab or clinic and told us the result

I don't know

reset

Self-reported race of the patient that died

American Indian Alaskan Native

Asian

Black African American

Native Hawaiian Pacific Islander

White

Other

Unknown

Refused to answer

Is this an out of state case?

Yes

reset

As of June 16, 2023, the Minnesota Department of Health is no longer requiring correctional facilities and shelters to report individual COVID-19 cases. Facilities operating under a CLIA waiver should report positive, facility-administered COVID-19 tests using SimpleReport. Please use this form only to report outbreaks or other unusual situations, and COVID-19 deaths. Thank you!

Comment if you would like assistance from MDH regarding your COVID-19 response. Please include if you have any resource gaps or questions, and we will respond to the email listed above (i.e. testing, PPE, guidance, etc.).

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