Form assigned Hantavirus

Form Approved OMB No. 0920-0009

Hantavirus Pulmonary Syndrome Case Report Form Patient Identification

Please return with Diagnostic Specimen Submission Form to:

Special Pathogens Branch c/o DASH

1600 Clifton Rd. NE, Bldg 4, Rm. B-35 -FIPS- -YR-

Atlanta, GA 30329-4018 Ph: 404-639-1510 Fax: 404-639-1509

Information below is required for identification and meaningful interpretation of laboratory diagnostic results. HPS may not be confirmed without compatible clinical and/or exposure data.

Patient’s last name First name Middle initial

Street Address City County State Zip

Age:____ Sex: Male____ Female____ Occupation: ______________________

Ethnicity: Hispanic or Latino____ Not Hispanic or Latino____ Unk____

Race: American Indian/Alaska Native____ Asian____ Black or African American____
Native Hawaiian or Other Pacific Islander____ White____

History of any rodent exposure in 6 weeks prior to onset of illness? Yes____ No____ Unk____

If yes, type of rodent: Mouse____ Rat____ Other____ Rodent nest____ Unk____

Place of contact (town, county, state):

Symptom onset date:
Specimen acquisition date:

Signs and Symptoms:

Fever > 101ْ F or > 38.3ْ C Yes____ No____ Unk____

Thrombocytopenia (platelets ≤ 150,000 mm) Yes____ No____ Unk____

Elevated Hematocrit (Hct) Yes____ No____ Unk____

Elevated creatinine Yes____ No____ Unk____

WBC Total:____ Total Neutrophils:____% Band Neutrophils:____% Lymphocytes: ____%

Supplemental oxygen required? Yes____ No____ Unk____

Was patient intubated? Yes ____ No____ Unk____

CXR with unexplained bilateral interstitial

infiltrates or suggestive of ARDS? Yes____ No____ Unk____

Outcome of illness? Alive____ Dead____ Unk____

Was an autopsy performed? Yes____ No____ Unk____

Has specimen been tested for hantavirus at another laboratory? Yes____ No____ Unk____

If yes, where?____________ Type of specimen?____________ Results (i.e. titer, OD)____________

State Health Dept. reporting case:__________ State/Local ID number:_________ Date form completed:______

Person completing report: Phone number ____________________

Name of patients’s physician: Phone number ____________________

Centers for Disease Control and Prevention Unk=Unknown

Public reporting burden of this collection of information is estimated to average 20 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0009).