Case Report Form.doc

Swine Influenza Case Report Form (FAX to: 404-657-7517)State EPI ID # (epidemiology ID) _CDC EPI ID # _State lab specimen ID #1 _CDC lab specimen ID #1 _State lab specimen ID #2 _CDC lab specimen ID #2 _CDC (lab) unique ID # _Reported by:State: _ County: _ Date reported to state/local health department_/_/_Name of Person Reporting to CDC: Last Name: _ First Name: _ Phone Number :( )_-_ Fax Number :( )_-_ E-Mail: _At the time of this report, is the case: Probable Confirmed (please see: www.cdc.gov/swineflu for case definitions)Patient Demographic Data:Date of Birth (mm/dd/yy): _/_/_Race: American Indian/Alaska NativeWhite Asian Black Native Hawaiian/Other Pacific Islander MultiracialEthnicity: Hispanic Non-HispanicSex: Male Female If Female, is the patient pregnant? Yes (weeks pregnant)_ No UnknownClinical Data:Date of symptom onset (mm/dd/yy): _/_/_Signs and symptoms: (check all that apply) Fever >37.8 C (100 F) _T max Sore throat Feverish but temperature not taken Conjunctivitis Cough Shortness of breath Headache Diarrhea Seizures Vomiting Rhinorrhea Other, specify _Was the patient hospitalized? Yes No UnknownWas the patient admitted to the intensive case unit? Yes No UnknownDid the patient require mechanical ventilation? Yes No UnknownDid the patient die as a result of this illness? Yes No UnknownMedical History:Did the case-patient receive influenza vaccine between September 2008 and March 2009? Yes No Dont KnowIf yes: Number of doses: 1 Date (mm/dd/yy) _/_/_If day unknown use 15 Type of vaccine: Inactivated (injectable) Live Attenuated (spray) Unknown 2 Date (mm/dd/yy) _/_/_If day unknown use 15Type of vaccine: Inactivated (injectable) Live Attenuated (spray) UnknownDoes the case-patient have any of the following?a.Asthma yes no unknown b. Other chronic lung disease yes no unknown c. Chronic heart or circulatory disease yes no unknownd. Metabolic disease (incl diabetes mellitus) yes no unknown e. Kidney disease yes no unknownf. Cancer in the last 12 months yes no unknowng. Immunosuppressive condition (HIV infection, chronic corticosteroid therapy, or organ transplant recipient) yes no unknownh. Other chronic diseases yes no unknowni. Neurological disease yes no unknownDiagnostic Findings:General testsLeukopenia(white blood cell count <5,000 leukocytes/mm3) Yes No UnknownLymphopenia (total lymphocytes <800/mm3 or lymphocytes <15% of total WBC) Yes No UnknownThrombocytopenia (total platelets <150,000/mm3) Yes No UnknownDid the patient have any of the following tests? Chest X-rayIf yes, Normal Abnormal Unknown Chest CT scan If yes, Normal Abnormal UnknownIf chest x-ray or chest CT scan result abnormal:Was there evidence of pneumonia? Yes No UnknownDid the patient have acute respiratory distress syndrome (ARDS)?  Yes No UnknownInfluenza testingTest 1 Date collected (mm/dd/yy): _/_/_State Lab Specimen1 ID: _Specimen TypeTest TypeResultsInfluenza Type/Subtype _ Enter specimen code RT-PCR/PCR DFA/IFA Viral culture HI Rapid test Immunohistochemistry Other positive negative indeterminate flu A flu B flu A/H1 flu A/H3 flu A unsubtypable flu A swine H1 Specimen code and type: 1. Nasopharyngeal swab 2. Nasopharyngeal aspirate 3. Oropharyngeal/throat swab 4. Nasal aspirate/swab 5. Endotracheal aspirate 6. Serum 7. Broncheoalveolar lavage specimen (BAL) 8. Sputum 9. Cerebrospinal fluid (CSF) 10. Tissue 11. Stool 12. Urine 13. Pleural fluid 14. Peritoneal fluid 15. Pericardial fluid 16. Chest fluid 17. OtherTest 2 Date collected (mm/dd/yy): _/_/_State Lab Specimen2 ID: _Specimen TypeTest TypeResultsInfluenza Type/Subtype _ Enter specimen code RT-PCR/PCR DFA/IFA Viral culture HI Rapid test Immunohistochemistry Other positive negative indeterminate flu A flu B flu A/H1 flu A/H3 flu A unsubtypable flu A swine H1 Specimen code and type: 1. Nasopharyngeal swab 2. Nasopharyngeal aspirate 3. Oropharyngeal/throat swab 4. Nasal aspirate/swab 5. Endotracheal aspirate 6. Serum 7. Broncheoalveolar lavage specimen (BAL) 8. Sputum 9. Cerebrospinal fluid (CSF) 10. Tissue 11. Stool 12. Urine 13. Pleural fluid 14. Peritoneal fluid 15. Pericardial fluid 16. Chest fluid 17. OtherSpecimens sent to CDCIndicate when and what type of specimens (including sera) were sent to CDC and specimen ID Date: _/_/2009 Specimen type (enter specimen code) _, State Lab Specimen ID A:_ Date: _/_/2009 Specimen type (enter specimen code) _, State Lab Specimen ID B:_ Date: _/_/2009 Specimen type (enter specimen code) _, State Lab Specimen ID C:_ Specimen code and type: 1. Nasopharyngeal swab 2. Nasopharyngeal aspirate 3. Oropharyngeal/throat swab 4. Nasal aspirate/swab 5. Endotracheal aspirate 6. Serum 7. Broncheoalveolar lavage specimen (BAL) 8. Sputum 9. Cerebrospinal fluid (CSF) 10. Tissue 11. Stool 12. Urine 13. Pleural fluid 14. Peritoneal fluid 15. Pericardial fluid 16. Chest fluid 17. OtherTreatment:Did the patient receive antiviral medications? Yes No UnknownIf yes, complete table belowDrugDate InitiatedDate DiscontinuedDosage (if known)Oseltamivir(Tamiflu®)Zanamivir(Relenza®)RimantidineAmantadineOther _Epidemiologic Risk FactorsThe following questions concern the 7 days prior to illness onset:Did the patient travel to Mexico? Yes No UnknownDid the patient have close contact (within 2 meter (6 feet) with a person (e.g. caring for, speaking with, or touching) who is a suspected, probable or confirmed swine influenza case*? Yes No UnknownDid the patient handle samples (animal or human) suspected of containing influenza virus in a laboratory or other setting? Yes No UnknownDoes the patient work in a health care facility or setting? Yes No UnknownHas the patient had family members or close contacts with pneumonia or influenza-like illness? Yes No UnknownHousehold Transmission (A household member is anyone including the case-patient with at least one overnight stay +/-7days from illness onset)How many people live in the household (include patient in this number)? _For each person in the household, besides the patient, record age, check applicable symptoms if present anytime from 7 days before to 7 days after the patients onset date, and record intital symptom onset datePerson #Code*Age(years)No symptomsFeverishMax temp >37.8C or >100 FCoughSore throatRunny noseDiarrheaOnset date1_/_/20092_/_/20093_/_/20094_/_/20095_/_/20096_/_/20097_/_/20098_/_/20099_/_/200910_/_/2009*Use to complete the relationship of the household member to the patient: 1=spouse, 2=mother, 3=father, 4=child, 5=sister, 6=brother, 7=cousin, 8=aunt, 9=uncle, 10=grandmother, 11=grandfather, 12=not related, 19=otherIf any of the patients household members been tested for influenza, please complete contact tracing form for each household member.* Please refer to www.cdc.gov/swineflu for case definition