Pandemic Influenza Plan - Questar III

Appendix 8-A
Home or Community-Based Facility Isolation or Quarantine Assessment Checklist
Although the home is generally the preferred setting for quarantine, alternative sites for
quarantine may be necessary in certain situations. For example, persons who do not have a home
situation suitable for this purpose or those who require quarantine away from home (e.g., during
travel) will need to be housed in an alternative location. Because persons who have been exposed
to influenza may require quarantine for as long as 10 days, it is important to ensure that the
environment (home or facility) is conducive to meeting the individual’s ongoing physical,
mental, and medical needs. Ideally, one or more community-based facilities that could be used
for quarantine should be identified and evaluated as part of influenza preparedness planning. The
home or facility evaluation should be performed on site by a public health official or designee.
Date: ______/______/_________
Tracking ID/Bar Code
Patient/Facility Name:
_____________________________________________
Address:
___________________________________________________________
___________________________________________________________
Patient Telephone Number
(______) ______ - ____________
Primary Caregiver Name: Last______________________First:___________________________
Primary Caregiver Telephone Number
(______) ______ - ____________
Inspectors Name: Last_________________________First: __________________________
Type of Home/Facility
- Single Family/Single Unit
- Single Family/Multiple Unit
- Single Family/Apartment
- Community-Based Facility (describe) ______________________________________
- Other (describe)________________________________________________________
Number of Occupants in home/facility____________________
______
______
Number of (bed)rooms
Number of bathrooms
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