Report HAI/AR-related event/clusters or organism(s)

Healthcare-associated infections (HAIs) are infections acquired while receiving care for another condition and can occur in any healthcare setting, including hospitals, surgical centers, dialysis facilities, and long-term care facilities. Use this form to report any HAI/AR-related events, clusters, or organisms, as well as unusual increases in infections or unexplained deaths that may be due to infectious causes, to the Nebraska Department of Health and Human Services. A DHHS staff member will contact you within one business day. If you do not receive a response and the matter is urgent, please call 402-471-7043, 402-219-3115, or 531-530-7407. All information provided is confidential.

Here is a general list of HAI/AR organisms: Acinetobacter (all species), Burkholderia cepacia, Candida auris, Carbapenem-resistant Enterobacterales (suspected or confirmed), Citrobacter species, Clostridioides difficile, Creutzfeldt-Jakob Disease (CJD) (suspected or confirmed), ESBL-producing Enterobacterales, Gram-negative bacteria, Hepatitis, Human Immunodeficiency Virus (HIV/AIDS), Influenza, Klebsiella species, Legionellosis, Methicillin-resistant Staphylococcus aureus (MRSA), Nontuberculous Mycobacteria (NTM), Norovirus, Pseudomonas aeruginosa, Serratia species, Staphylococcus aureus, Tuberculosis (TB), Vancomycin-resistant Enterococci (VRE), Vancomycin-intermediate Staphylococcus aureus, and Vancomycin-resistant Staphylococcus aureus.

***For those who are required to report to the state (i.e., laboratories, healthcare personnel), this tool is not a substitute for reporting mandatory reportable disease/illness to the state. Please report according to the requirements as specified by Nebraska Reportable Disease Title 173 Rules and Regulations and inform your local health department if required in addition to using the reporting system.

Name of the organism confirmed or under suspicion

* must provide value

If other, please specify:

Specimen source
(If lab-confirmed test) and (on first initial patient if more than 1 patient with illness)

* must provide value

If other specimen source, please specify:

Specimen collection date
(If lab-confirmed test; on first initial case if more than 1 patient)

M-D-Y

How many patients are suspected or confirmed of having this reported illness?

More than 3

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Name of Index Patient

Date of Birth of Index Patient

M-D-Y

Name of Patient #2

Date of Birth of Patient #2

M-D-Y

Name of Patient #3

Date of Birth of Patient #3

M-D-Y

Name of Patient #4

Date of Birth of Patient #4

M-D-Y

Name of Patient #5

Date of Birth of Patient #5

M-D-Y

Name of the person reporting

* must provide value

Email of the person reporting

* must provide value

Phone number of the person reporting

* must provide value

Name of organization/facility/laboratory affiliation of the person reporting

What is the best way to reach you (email, phone, time)?

Please include additional contact information AND any other person's contact information who would be able to answer questions in your absence.

* must provide value

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Reminder: If your facility suspects an outbreak, please also notify your local health department surveillance coordinator. You can find your local health department contact information HERE.

If you suspect a norovirus outbreak, please begin tracking illnesses using a patient-centric Gastrointestinal Line List as an outbreak management tool.

Someone from DHHS will respond to your notification within 24 hours.

Thank you!

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