Document

Patient Identifiers and Other Information

ICR 200805-0920-002 · OMB 0920-0806 · Object 6906401.

Document Viewer [doc]

Status: Original and derived artifacts are available for this document.

Download: doc | pdf | html

Primary: htmlSource: application/msword

Loading document viewer…

Document Metadata

Record metadata
File Type	application/msword
File Title	Patient Identifiers and Other Information
Author	gcx3
Last Modified By	Writer
File Modified	2008-02-04
File Created	2026-08-31
Conversion State	complete

Extracted Text

PATIENT IDENTIFIERS AND OTHER INFORMATION NOT FOR TRANSMISSION TO CDC
Last Name:
___________________________
First Name:
___________________________
Name Emergency Contact 1:
_____________________________
Name Emergency Contact 2:
___________________________
Phone No.:
___________________________
Chart Number:
___________________________
Additional Numeric ID:
_____________________________
Additional Numeric ID:
___________________________
Address:
_________________________________________________________
City:
_____________________________
Zip:
___________________________
Primary provider name:
_________________________________________________________
Provider Phone No.:
_____________________________

Open text field for site use:

_______________________________________________________________________________________________________________________
Name of person reporting this case:
Last Name:
___________________________

First Name:
_____________________________

Date Reported:
______-______-__________ MM-DD-YYYY

Enrollment Information
1. State (residence of patient):

____ ____
2. County:

_____________________________
3. Case I.D.:
____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
4. Hospital I.D. Where Patient Treated:

____ ____ ____ ____ ____
a) Admission Date: ______-______-_______ (MM-DD-YYYY)

b) Discharge Date: ______-______-_______ (MM-DD-YYYY)
5. Was patient transferred from another hospital:
 Yes
 No
a) If YES, Hospital I.D.:

____ ____ ____ ____ ____
b) Admission Date: ______-______-________ (MM-DD-YYYY)

c) Transfer Date: ______-______-________ (MM-DD-YYYY)
6. Was patient a resident of nursing home or other chronic care facility prior to hospitalization?
 Yes
 No

a) If YES, indicate name of facility: _______________________________

7. Date of Birth:

_____-_____-_________
(MM-DD-YYYY)

7b. Age:
_____ years
8. Sex:

 Male
 Female

9. Ethnicity:
10. Race (check all that apply):
 White
 Asian
 Black or African American
 Native Hawaiian or Other Pacific Islander
 American Indian or Alaskan Native
 Multiracial, unspecified
 Not Specified

 Hispanic or Latino

 Non-Hispanic or Latino

 Not Specified

POSITIVE Laboratory Testing Results for Influenza
1. How was the diagnosis of influenza confirmed (check all positive tests for influenza):


Fluorescent antibody (Direct or Indirect FA)

RT-PCR


Viral culture

Test method unknown


Rapid Influenza test..……Please record name of test: ________________________________________________
2. Date of first positive influenza test: _____-_____-_______ (MM-DD-YYYY)

3. Influenza virus identification (check only one type):  Influenza A  Influenza B  Type unknown
a) If Influenza A subtype, please specify if known: __________________________________________________________________
4. Hospital/lab/office ID where positive result was identified (If done in a doctor’s office, use the code MDTST
or if site of flu testing is unknown, use UNKLB) : ____ ____ _____ _____ _____

a) If Influenza A subtype, please specify if known: _______(ASubtype)____________________________________________________________

5. Was a positive influenza test result noted in the admission H&P or discharge note?  Yes  No

From the face sheet, list ICD-9 discharge diagnoses (if available)

1.

4.

7.


2.

5.

8.


3.

6.

9.


From the Admission History and Physical

1. Date of onset of acute illness episode resulting in hospitalization : ______-______-________ (MM-DD-YYYY)  Unknown

2. Did the patient have any of the following conditions?
 Yes
 No

a) If YES, please check all that apply:

 Asthma (including reactive airway disease)
 Cancer diagnosis in last 12 months, excluding nonmelanoma skin cancer

 Cystic fibrosis
 Immunosuppressive condition

 Other chronic lung disease
(Specify)_____________________
 Seizure disorder

 Chronic cardiovascular disease
(Specify)________________________
 History of Guillain-Barre Syndrome

 Chronic metabolic disease (including Diabetes)
(Specify) ________________________
 History of lymphoma, leukemia

 Renal disease
(Specify) __________________________
 Cognitive dysfunction

 Hemoglobinopathy (including Sickle Cell Disease)
 Pregnant (Specify expected date of confinement, EDC):
_____-_____-_________ (MM-DD-YYYY )  Unknown

 Neuromuscular disorder (including Cerebral Palsy)
(Specify) _____________________________

Tests, Procedures, and Interventions during the Hospital Stay

1. Chest X-Ray/CT (any during admission)
 Yes
 No

a) If YES, was there a new infiltrate or consolidation?
 Yes
 No

2. Mechanical ventilation
 Yes
 No

Culture Confirmation of Secondary Bacterial Pathogens

1. Was there culture confirmation of an invasive bacterial infection (sterile site)?
 Yes
 No

2. Date of first positive culture ______-______-________ (MM-DD-YYYY)

3. Specify the pathogen identified (check only one):

 Streptococcus pneumoniae
 Group A Streptococcus
 Haemophilus influenzae: If YES, type b?  Yes  No  Unknown

 Staphylococcus aureus: If YES, methicillin resistant (MRSA)?  Yes  No  Unknown

 Neisseria meningitidis (specify serogroup if known):___________________

4. Specify the site(s) in which the pathogen was identified (check all that apply):

 Blood
 Pleural fluid  Endotracheal aspirate

 Cerebrospinal fluid (CSF)
 Sputum

Please specify any other sterile sites not listed above:_________________________________________________________________

5. If other pathogens were isolated from sterile sites within 2 days of hospital admission, please list below and specify first culture date and sterile site in which pathogen was identified:________________________________________________________________________________________

Use of Statins (cholesterol lowering medicine)

1. Was the patient taking a statin before hospital admission? (check only one)
 Yes
 No
 Unknown

a
If YES, specify name of statin (enter code): _________

2. Did the patient receive statins any time during hospitalization? (check only one)
 Yes
 No
 Unknown

a
If YES, specify name of statin (enter code): _________

Treatment of Influenza
1. Did the patient receive treatment with an antiviral medication for influenza at any time during the
course of this illness?
 Yes
 No
a. If YES, indicate which antiviral medication was used for treatment:
 Amantadine (Symmetrel)
 Zanamivir (Relenza)
 Rimantadine (Flumadine)
 Oseltamivir (Tamiflu)
 Unknown

b. Was antiviral treatment started before hospital admission?
 Yes  No  Unknown
c. Indicate antiviral treatment start date: ____-____-______ (MM-DD-YYYY)  Unknown
From the Discharge Summary
1. Was this patient admitted to an intensive care unit (ICU)?
 Yes
 No
2. Did the patient have any of the following diagnoses at discharge (check all that apply)?

Pneumonia
Yes
No

Stroke (CVA)
Yes
No

Acute encephalopathy/encephalitis
Yes
No

3. What was the outcome of the patient?


Died


Alive

a)
If discharged alive, please indicate to where:


Home


Other hospital


Long-term care facility / rehabilitation center


Hospice


Other


Unknown
Case Identification Method
1. What is the case identification method (check only one)?


Initial Surveillance

Discharge data audit

If Initial Surveillance, specify case finding source (check all that apply):
 Hospital log

 Laboratory list

 Reportable disease

 Discharge Database

If other case finding sources were used, please list: ______________________________________________________________
Influenza Vaccination History
1. Did the patient receive any influenza vaccine during fall or winter of the current
influenza season (i.e., at least 2 weeks prior to hospitalization)?
 Yes
 No
 Unknown
2. If YES, please specify vaccine type:
 Injected vaccine --Trivalent inactivated influenza vaccine (TIV)
 Nasal spray -- Live-attenuated influenza vaccine (LAIV)
 Unknown
3. What was the source of vaccination history (check all that apply)?
 Medical chart

 Primary care provider

 Interview

a) If vaccination history obtained by phone interview, specify source of interview:

 Patient

 Proxy

Specify relationship (enter code): _____

COMMENTS: _____________________________________________________________________________________________