Form 2 Pediatric Influenza Hospitalization Surveillance Project

Form Approved

OMB No. 0920-08AB

Exp. Date xx/xx/20xx

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)

6a. Date of Birth: _____-_____-_________ (MM-DD-YYYY) 6b. Age: ____years ____ months

7. Sex:  Male  Female

8. Ethnicity:

9. 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) : _____ _____ _____ _____ _____

5. Was a positive influenza test result noted in the admission H&P or discharge note?

 Yes

 No

F rom 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)

 Immunosuppressive condition (Specify)___________________________________________

 Cystic fibrosis

 Other chronic lung disease (Specify)____________________________________

 Seizure disorder

 Chronic cardiovascular disease (Specify)____________________________________

 History of febrile seizures

 Chronic metabolic disease (including Diabetes) (Specify) ____________________________________

 Premature (gestational age <37 weeks at birth for patients <2 yrs of age) (Specify gestational age at birth, in weeks): _____ _____  Unknown

 Renal disease (Specify) ___________________________________

 Developmental delay

 Hemoglobinopathy (including Sickle Cell Disease)

 Pregnant (Specify expected date of confinement, EDC): _____-_____-_________ (MM-DD-YYYY )  Unknown

 Neuromuscular disorder (including Cerebal Palsy) (Specify) _____________________________________

 Long-term aspirin therapy

 Abnormality of the upper airway (Specify) _____________________________________________

Tests, Procedures, and Interventions during the Hospital Stay

1. Chest X-Ray (any during admission)

 Yes

 No

3. Extracorporeal Membrane Oxygenation (ECMO or ‘on bypass’)

 Yes

 No

a) If YES, was there an infiltrate or consolidation?

 Yes

 No

4. CT Scan/MRI of head or brain

 Yes

 No

2. Mechanical ventilation

 Yes

 No

a) If YES, were there any neurologic abnormalities?

 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 meningitides (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, please list below and specify first culture date and sterile site in which pathogen was identified: ___________________________________________________________________________________________________________________

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

Bronchiolitis

Yes

No

Encephalopathy/encephalitis

Yes

No

Seizures

Yes

No

Reye’s syndrome

Yes

No

Hemophagocytic Syndrome

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: ______________________________________________________________________

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 (check all that apply):  Injected vaccine --Trivalent inactivated influenza vaccine (TIV)  Nasal spray -- Live-attenuated influenza vaccine (LAIV)  Unknown a) Indicate number of doses:  1  2  Unknown For each dose, specify the date given 1) _____-_____-________ (MM-DD-YYYY) 2) _____-_____-________ (MM-DD-YYYY)

3. Did the patient receive any influenza vaccine in previous seasons?

 Yes

 No

 Unknown

4. Did the patient receive pneumococcal conjugate vaccine at any age (for children born in or after 1998)?

 Yes

 No

 Unknown

a) If YES, please complete the list below. Dose Date Given (MM-DD-YYYY) 1 _____-_____-_________ 2 _____-_____-_________ 3 _____-_____-_________ 4 _____-_____-_________

5. What was the source of vaccination history (check all that apply)?

 Medical chart

 Primary care provider

 Interview

C

Public reporting burden of this collection of information is estimated to average 80 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-08AB) 

OMMENTS: ______________________________________________________________________________________________

2007-08 season page 4 of 4

13September2007