Form 2 Pediatric Influenza Hospitalization Surveillance Project

All Age Influenza Hospitalization Surveillance Project

Attachment 4 Peds Case Report Form

Pediatric Influenza Hospitalization Surveillance Project

OMB: 0920-0806

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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


  1. 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

File Typeapplication/msword
File TitleAppendix 2: Pediatric Case Report Form
AuthorAdministrator
Last Modified ByAdministrator
File Modified2008-02-04
File Created2008-02-04

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