2011-12 FluSurv-NET Influenza Hospitalization Surveilance Project Case Report Form

Case ID: 1 1 1 2 .

2011-12 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/xxxx

A. Patient Data – THIS INFORMATION IS NOT SENT TO CDC
Last Name:	First Name:	Phone Number 1:	Phone Number 2:
Emergency Contact 1:		Emergency Contact 2:
Street Address:		City:	Zip:
Chart Number:	Primary Provider Name:	Provider Phone Number:	Provider Fax Number:
Site Use 1:		Site Use 2:
Site Use 3:		Site Use 4:

B. Reporter Information

1. Reporter Name: _____________________________________

2. Date Reported: ____/ ____/ ____

C. Enrollment Information

1. Case Classification:

 Prospective Surveillance

2. State:

3. County:

 Audit

____________________

__________________

4. Case Type:

 Pediatric

5. Date of Birth:

6. Age:

 Years

 Days (if < 1 month)

7. Sex:

 Male

 Adult

____/ ____/ ____

_________

 Months (if < 1 yr)

 Female

8. Race:

 White

 Black or African American

 Asian/Pacific Islander

9. Ethnicity:

 Hispanic or Latino

 American Indian or Alaska Native

 Multiracial

 Not specified

 Non-Hispanic or Latino

 Not Specified

10. Hospital ID Where Patient Treated:

10a. Admission Date:

10b. Discharge Date:

___________

_____/ _____/ _____

_____/ _____/ _____

11. Was patient transferred from another hospital?

 Yes

 No

 Unknown

11a. Transfer Hospital ID:

11b. Transfer Hospital

11c. Transfer Date:

___________

Admission Date:

_____/ _____/ _____

_____/ _____/ _____

12. Was patient a resident of an institutional setting or other chronic care facility prior to hospitalization (e.g., nursing home, prison, long-term care facility)?

 Yes

 No

 Unknown

12a. If yes, indicate TYPE of facility: __________________________

12b. If yes, indicate NAME of facility: __________________________

13. Does patient work in the healthcare industry?

 Yes

 No

 Unknown

D. Influenza Testing Results

1. Test 1:

 Rapid

 RT-PCR

 Viral Culture

 Serology

 Fluorescent Antibody

 Method Unknown/Note Only

1a. Result:

 Flu A (not subtyped)

 Flu B

 Flu A & B

 Flu A/B (Not Distinguished)

 2009 H1N1

 H1, Seasonal

 H1, Unspecified

 H3

 Flu A, Unsubtypable

 Negative

 Unknown

 Other, specify: _________________________________________________

1b. Specimen collection date: ___/___/ ___

1c. Testing facility ID: __________________

1d. Specimen ID: _______________________

2. Test 2:

 Rapid

 RT-PCR

 Viral Culture

 Serology

 Fluorescent Antibody

 Method Unknown/Note Only

2a. Result:

 Flu A (not subtyped)

 Flu B

 Flu A & B

 Flu A/B (Not Distinguished)

 2009 H1N1

 H1, Seasonal

 H1, Unspecified

 H3

 Flu A, Unsubtypable

 Negative

 Unknown

 Other, specify: _________________________________________________

2b. Specimen collection date: ___/___/ ___

2c. Testing facility ID: __________________

2d. Specimen ID: _______________________

3. Test 3:

 Rapid

 RT-PCR

 Viral Culture

 Serology

 Fluorescent Antibody

 Method Unknown/Note Only

3a. Result:

 Flu A (not subtyped)

 Flu B

 Flu A & B

 Flu A/B (Not Distinguished)

 2009 H1N1

 H1, Seasonal

 H1, Unspecified

 H3

 Flu A, Unsubtypable

 Negative

 Unknown

 Other, specify: _________________________________________________

3b. Specimen collection date: ___/___/ ___

3c. Testing facility ID: __________________

3d. Specimen ID: _______________________

4. Test 4:

 Rapid

 RT-PCR

 Viral Culture

 Serology

 Fluorescent Antibody

 Method Unknown/Note Only

4a. Result:

 Flu A (not subtyped)

 Flu B

 Flu A & B

 Flu A/B (Not Distinguished)

 2009 H1N1

 H1, Seasonal

 H1, Unspecified

 H3

 Flu A, Unsubtypable

 Negative

 Unknown

 Other, specify: _________________________________________________

4b. Specimen collection date: ___/___/ ___

4c. Testing facility ID: __________________

4d. Specimen ID: _______________________

Public reporting burden of this collection of information is estimated to average 15 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-xxxx).

E. Admission and Patient History

1. Was patient discharged from any hospital within one week prior to the current admission date?

 Yes

 No

 Unknown

2. Reason for current admission (Check all that apply):

 Acute respiratory illness

 Asthma and/or COPD exacerbation

 Pneumonia

 Other respiratory or cardiac conditions

 Other, neither respiratory nor cardiac conditions

 Unknown

3. Date of onset of acute illness resulting in hospitalization:

 Unknown

4. Date of onset of respiratory symptoms:

 Unknown

____/ ____/ ____

____/ ____/ ____

5. Body Mass Index:

6. Height:

 Inches  Cm

 Height Unknown

7. Weight:

 Lbs  Kg

 Weight Unknown

______

_________

___________

8. Did patient have any of the following pre-existing medical conditions? Check all that apply.

 Yes

 No

 Unknown

8a. Chronic Lung Disease

 Yes

 No/Unknown

8f. Chronic Metabolic Disease

 Yes

 No/Unknown

 Asthma/Reactive airway disease

 Diabetes

 Cystic fibrosis

 Thyroid dysfunction

 Emphysema/COPD

 Other, specify: ________________________________________

 Other, specify ________________________________________

8g. Blood disorders/Hemoglobinopathy

 Yes

 No/Unknown

8b. Cardiovascular Disease

 Yes

 No/Unknown

 Sickle cell disease

 Atherosclerotic cardiovascular disease (ASCVD)

 Splenectomy/Asplenia

 Cerebral vascular incident/Stroke

 Other, specify ________________________________________

 Congenital heart disease

 Coronary artery disease (CAD)

8h. Renal Disease

 Yes

 No/Unknown

 Heart failure/CHF

 Chronic kidney disease/chronic renal insufficiency

 Other, specify ________________________________________

 End stage renal disease/Dialysis

 Glomerulonephritis

8c. Neurologic disorder

 Yes

 No/Unknown

 Nephrotic syndrome

 Cerebral palsy

 Other, specify _______________________________________

 Cognitive dysfunction

 Dementia

8i. History of Guillain-Barré Syndrome

 Yes

 No/Unknown

 Developmental delay

 Down syndrome

8j. Other

 Yes

 No/Unknown

 Plegias/Paralysis

 Alcohol abuse

 Seizure/Seizure disorder

 Current smoker

 Other, specify: ________________________________________

 Liver disease

 Morbidly obese (ADULTS ONLY)

8d. Neuromuscular disorder

 Yes

 No/Unknown

 Mitochondrial disorder

 Duchenne muscular dystrophy

 Obese

 Muscular dystrophy

 Pregnant

 Multiple sclerosis

If pregnant, specify gestational age in weeks: ___________

 Other, specify: ________________________________________

 Unknown gestational age

 Post-partum (two weeks or less)

8e. Immunocompromised Condition

 Yes

 No/Unknown

 Other, specify ________________________________________

 AIDS or CD4 count < 200

______________________________________________________

 Bone marrow transplant

______________________________________________________

 Cancer diagnosis in last 12 months

______________________________________________________

 Complement deficiency

______________________________________________________

 History of lymphoma or leukemia

 HIV Infection

8k. PEDIATRIC CASES ONLY

 Hodgkin’s disease/lymphoma

Abnormality of upper airway

 Yes

 No/Unknown

 Immunoglobulin deficiency

History of febrile seizures

 Yes

 No/Unknown

 Immunosuppressive therapy

Long-term aspirin therapy

 Yes

 No/Unknown

 Multiple myeloma

Premature

 Yes

 No/Unknown

 Organ transplant

(gestation age < 37 weeks at birth for patients < 2yrs)

 Steroid therapy

If yes, specify gestation age at birth in weeks: _____________

 Other, specify ________________________________________

 Unknown gestational age at birth

F. Test, Procedures and Interventions During Hospital Stay

1. Did patient receive mechanical ventilation?

 Yes

 No

 Unknown

2. Did patient receive extracorporeal membrane oxygenation (ECMO or ‘on bypass’)?

 Yes

 No

 Unknown

G. Bacterial Pathogens

1. Was there culture confirmation of a bacterial infection within 3 days (collection date) of admission?

 Yes

 No

 Unknown

2. If yes, specify:

2a. Pathogen 1: _____________________________________________

2b. Date of culture: ____/ ____/ ____

2c. If Staphylococcus aureus, specify:

 Methicillin resistant (MRSA)

 Methicillin sensitive (MSSA)

 Sensitivity unknown

2d. If Haemophilus influenzae, specify if type B:

 Yes

 No

 Unknown

2e. If Neisseria meningitidis, specify serogroup:

 B

 C

 Y

 Other, specify: __________________

 Unknown

2f. Site where pathogen identified:

 Blood

 Cerebrospinal fluid (CSF)

 Bronchoalveolar lavage (BAL)

 Sputum

 Endotracheal aspirate

 Pleural fluid

 Other, specify: _______________________________

3. If multiple pathogens identified, specify:

3a. Pathogen 2: _____________________________________________

3b. Date of culture: ____/ ____/ ____

3c. If Staphylococcus aureus, specify:

 Methicillin resistant (MRSA)

 Methicillin sensitive (MSSA)

 Sensitivity unknown

3d. If Haemophilus influenzae, specify if type B:

 Yes

 No

 Unknown

3e. If Neisseria meningitidis, specify serogroup:

 B

 C

 Y

 Other, specify: __________________

 Unknown

3f. Site where pathogen identified:

 Blood

 Cerebrospinal fluid (CSF)

 Bronchoalveolar lavage (BAL)

 Sputum

 Endotracheal aspirate

 Pleural fluid

 Other, specify: _______________________________

H. Viral Pathogens

1. Was patient tested for any of the following viral pathogens within 3 days of admission?

 Yes

 No

 Unknown

1a. Respiratory syncytial virus/RSV

 Yes, positive

 Yes, negative

 Not tested/Unknown

Date: ____/____/____

1b. Adenovirus

 Yes, positive

 Yes, negative

 Not tested/Unknown

Date: ____/____/____

1c. Parainfluenza 1

 Yes, positive

 Yes, negative

 Not tested/Unknown

Date: ____/____/____

1d. Parainfluenza 2

 Yes, positive

 Yes, negative

 Not tested/Unknown

Date: ____/____/____

1e. Parainfluenza 3

 Yes, positive

 Yes, negative

 Not tested/Unknown

Date: ____/____/____

1f. Human metapneumovirus

 Yes, positive

 Yes, negative

 Not tested/Unknown

Date: ____/____/____

1g. Rhinovirus

 Yes, positive

 Yes, negative

 Not tested/Unknown

Date: ____/____/____

1h. Other, specify: _________________

 Yes, positive

 Yes, negative

 Not tested/Unknown

Date: ____/____/____

I. Influenza Treatment

1. Did the patient receive treatment with an antiviral medication for influenza at any time during the course of this illness?

 Yes

 No

 Unknown

1a. If yes, indicate which antiviral medication(s) were used, or check unknown:

 Antiviral Medication(s) Unknown

Series 1

Series 2

Treatment

Start Date

End Date

Frequency and Dose

Start Date

End Date

Frequency and Dose

 Amantadine (Symmetrel)

 Rimantadine (Flumadine)

 Zanamivir (Relenza)

Dose: _______________

Dose: ________________

 QD  BID  TID

 QD  BID  TID

 Oseltamivir (Tamiflu)

Dose: _______________

Dose: ________________

 QD  BID  TID

 QD  BID  TID

 Other, specify:

Dose: _______________

Dose: ________________

___________________

 QD  BID  TID

 QD  BID  TID

2. Additional Treatment Comments:

J. Chest Radiograph During Hospital Stay

1. Was a chest x-ray taken within 3 days of admission?

 Yes

 No

 Unknown

2. Were any of these chest x-rays abnormal?

 Yes

 No

 Unknown

2a. Date of first abnormal chest x-ray:

____/____/____

2b. For first abnormal chest x-ray, please check all that apply:

 Report not available

 Bronchopneumonia/pneumonia

 Cannot rule out pneumonia

 Air space density/opacity

 Consolidation

 Interstitial infiltrate

 Pleural effusion

 Single lobar infiltrate

 Multiple lobar infiltrate (unilateral or bilateral)

 Other, specify: _________________________________________________________________________________________________________

K. Discharge Summary

1. Was the patient admitted to an intensive care unit (ICU)?

 Yes

 No

1a. Date of ICU Admission:

____/____/____

 Unknown

 Unknown

1b. Date of ICU Discharge:

____/____/____

 Unknown

2. Did the patient have any of the following diagnoses at discharge (check all that apply)?

Pneumonia

 Yes

 No

 Unknown

Stroke (CVI)

 Yes

 No

 Unknown

Guillain-Barré syndrome

 Yes

 No

 Unknown

Acute myocarditis

 Yes

 No

 Unknown

Acute encephalopathy/ encephalitis

 Yes

 No

 Unknown

Acute respiratory distress syndrome (ARDS)

 Yes

 No

 Unknown

Seizures

 Yes

 No

 Unknown

Bronchiolitis

 Yes

 No

 Unknown

Reye’s syndrome

 Yes

 No

 Unknown

Hemophagocytic syndrome

 Yes

 No

 Unknown

3. What was the outcome of the patient?

 Alive

 Deceased

 Unknown

3a. If discharged alive, please indicate to where:

 Home

 Other hospital

 Hospice

 Long-term care facility

 Other, specify: _______________________

 Unknown

4. If patient was pregnant on admission, indicate pregnancy status at discharge:

 Still pregnant

 No longer pregnant

 Unknown

4a. If patient was pregnant on admission but no longer pregnant at discharge, indicate pregnancy outcome at discharge:

 Miscarriage

 Ill newborn

 Newborn died

 Healthy newborn

 Abortion

 Unknown

5. Additional notes regarding discharge: _____________________________________________________________________________________

L. ICD-9 Discharge Diagnoses

1.

4.

7.

2.

5.

8.

3.

6.

9.

M. Vaccination History

For mothers of patients < 6 months

1. Did patient’s mother receive the influenza vaccine during fall or winter of the current influenza season?

 Yes

 No

 Unknown

1a. If yes, specify mother’s vaccine type:

 Injected Vaccine – Trivalent inactivated influenza vaccine (TIV)

 Vaccine type unknown

 Nasal Spray – Live attenuated influenza vaccine (LAIV)

2. Did patient receive the influenza vaccine during fall or winter of the current influenza season

 Yes

 No

 Unknown

2a. If yes, specify dosage date information:

1) ___/___/___

2) (Pediatrics Only) ___/___/___

2b. If yes, specify patient’s vaccine type:

 Injected Vaccine – Trivalent inactivated influenza vaccine (TIV)

 Vaccine type unknown

 Nasal Spray – Live attenuated influenza vaccine (LAIV)

2c. If patient ≥ 18 years and received injected vaccine (TIV), please specify type:

 Regular IM

 High dose IM

 Intradermal

 TIV type unknown

3. If patient < 9 years, did patient receive any seasonal influenza vaccine in previous seasons?

 Yes

 No

 Unknown

4. Did patient receive any type of pneumococcal vaccine at any age?

 Yes

 No

 Unknown

4a. If yes, please provide dosage date information:

Dose 1 ___/ ___/ ___

Dose 2 ___/ ___/ ___

Dose 3 (Pediatrics Only) ___/ ___/ ___

Dose 4 (Pediatrics Only) ___/ ___/ ___

4b. If patient ≥ 65 years, was vaccine received within last five years?

 Yes

 No

 Unknown

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

 Medical Chart

 Vaccine Registry

 Primary Care Provider

 Interview

 Patient Refused/Lost

5a. If vaccination history obtained by phone interview, please specify source of interview:

 Patient

 Proxy

If proxy, specify relationship: ______________________________________________

N. Miscellaneous

1. Case Finding:

 Hospital Log

 Laboratory List

 Discharge Database

 Reportable Disease

 Other, specify: ____________

2. Additional Comments:

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