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pdfU.S. Influenza Sentinel Provider
Surveillance Network
State & Local
Health Departments
Participating
Providers
2005 -2006
Workfolder
DEPARTMENT OF HEALTH & HUMAN SERVICES • Centers for Disease Control and Prevention
.
CDC 55.20E REV. 06/2005 page 1 of 4
DEPARTMENT OF
HEALTH & HUMAN SERVICES
Centers for Disease Control
and Prevention (CDC)
Atlanta, Georgia 30333
U.S. I NFLUENZA S ENTINEL P ROVIDER
S URVEILLANCE W ORKFOLDER
U.S. INFLUENZA SURVEILLANCE
INFLUENZA BRANCH
DIVISION OF VIRAL AND RICKETTSIAL DISEASES
October 2, 2005 – September 30, 2006
INFLUENZA-LIKE ILLNESS (ILI) is defined as:
Provider ID:
Password:
Fever (>100°F [37.8°C] , oral or equivalent) AND cough and/or sore throat
(in the absence of a KNOWN cause other than influenza).
Summer 2006
2005–06 Season
Week
Ending
Date
OCT
NOV
DEC
JAN
FEB
MAR
APR
MAY
CDC
Date
Code
Form Approved
OMB No. 0920-0004
0–4
Yrs.
5–24
Yrs.
25–64
Yrs.
>64
Yrs.
Total
Patients
Seen*
Week
Ending
Date
CDC
Date
Code
8
0540
JUN 3
0622
15
0541
10
0623
22
0542
17
0624
29
0543
24
0625
5
0544
1
0626
12
0545
8
0627
19
0546
15
0628
26
0547
22
0629
3
0548
29
0630
10
0549
5
0631
17
0550
12
0632
24
0551
19
0633
31
0552
26
0634
7
0601
2
0635
14
0602
9
0636
21
0603
16
0637
28
0604
23
0638
4
0605
30
0639
11
0606
18
0607
25
0608
4
0609
11
0610
18
0611
25
0612
1
0613
8
0614
15
0615
22
0616
29
0617
6
0618
13
0619
20
0620
27
0621
CDC 55.20E REV. 06/2005 page 2 of 4
JUL
AUG
SEP
0–4
Yrs.
5–24
Yrs.
25–64
Yrs.
>64
Yrs.
Total
Patients
Seen*
*Total Patients seen for any reason = (non-ILI + ILI)
Thank you for participating in the
U.S. Influenza Sentinel Provider
Surveillance System.
Please do not discard this workfolder.
A postage paid envelope will be provided for
you to return the workfolder to CDC at the end
of the season (or summer if you participate in
year-round surveillance).
INFLUENZA-LIKE ILLNESS (ILI) is defined as:
Fever (>100°F [37.8°C] , oral or equivalent) AND cough and/or sore throat
(in the absence of a KNOWN cause other than influenza).
The presence or absence of other symptoms, such as body aches, fatigue, or vomiting, should be disregarded when classifying a patient as having an ILI.
Although this clinical definition by itself is very general, when combined with information on circulating viruses, the information on influenza-like illness
activity provides an excellent picture of influenza activity in the United States.
INSTRUCTIONS FOR INTERNET REPORTING
The sentinel provider Internet reporting site should be accessible by both Netscape (Version 5.0 and above)
and Internet Explorer (Version 5.0 and above) browsers.
To access the influenza sentinel provider Internet reporting system, go to:
http://www2.ncid.cdc.gov/flu/
Enter your provider ID code and password which can be found on the previous page and select Submit.
You will now be on the Main Menu page. From this page you may either enter or view your data.
To enter data:
1. Select Enter Data.
2. Select the four digit date code (e.g. 0540) for the week you wish to report and enter your data. Use the
enter or tab key to move from one data field to the next. Indicate if the report is an update from a
previously entered repor t .
Influenza Surveillance Program
Sentinel Provider Internet Reporting System
Data Input Page
1. Provider ID Code:
77001
2. Date Code:
0540 (Oct 8, 2005)
3. ILI AGE 0-4:
0
4. ILI AGE 5-24:
0
5. ILI AGE 25-64:
0
6. ILI AGE OVER 64:
0
7. TOTAL PATIENTS SEEN:
100
8. Is this a revision of data reported
on an earlier date?
Submit
NO ■
YES ■
Reset
Go To Main Menu
3. Select Submit. Your data has been transmitted to CDC and will be displayed on the screen. If the data
displayed are incorrect, select Go To Main Menu, re-enter the correct report, and indicate that this entry is a
revision of previously reported data.
4. Select Go To Main Menu. This will take you back to the Main Menu page. If you wish to enter data for
additional weeks, repeat steps 1 through 4.
In addition to entering and viewing your own data, you can also view the most recent influenza activity update.
CDC 55.20E REV. 06/2005 page 3 of 4
SENTINEL PROVIDER REPORTS
OF INFLUENZA-LIKE ILLNESS (ILI)
FORM APPROVED
OMB NO. 0920-0004
2005-2006 Influenza Surveillance
Report for the 7-day period ending ___/___/___
ID Number
(Period ends Saturday at midnight)
Check if
Revised
Report
Number of Patients with ILI
0-4 yrs.
(Pre-school)
5-24 yrs.
(School age)
25-64 yrs.
(Adults)
Influenza-like Illness
Fever (≥100° F [37.8° C], oral or
equivalent)
-AND cough and/or sore throat
(in the absence of a known cause other than influenza)
>64 yrs.
(Older Adults)
Total Number of Patients Seen For Any Reason
(Total of ILI + Non-ILI cases for all age groups combined)
DO NOT LEAVE BLANK.
WITHOUT THIS NUMBER, THE REPORT CANNOT BE USED.
FAX THIS FORM TO 1-888-232-1322
(NO COVER SHEET IS REQUIRED)
Public reporting burden of this collection of information is estimated to average 10 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 DHHS Reports
Clearance Officer; Paperwork Reduction Project (0920-0008); Rm 531H, H. H. Humphrey Bg.; 200 Independence Ave., SW, Washington, DC 20201.
CDC 55.20
REV. 6/05
File Type | application/pdf |
File Title | CDC 55.20E Cover 03 (single) |
Author | maw2 |
File Modified | 2005-06-23 |
File Created | 2003-07-22 |