FluSurv-NET Case Report

Case ID:

1 3 1 4

Form Approved
OMB No. 0920-0978
Exp. Date. 08/31/2016

2013-14 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form
A. Patient Data – THIS INFORMATION IS NOT SENT TO CDC
Last Name:

First Name:

Phone Number 1:

Phone Number 2:

Street Address:

City:

Zip:

Chart Number

Census Tract:

Emergency Contact 1:

Emergency Contact Phone:

Primary Provider
Name:
Site Use 1:

Provider Phone
Number:
Site Use 2:

Provider Fax
Number:
Site Use 3:

B. Reporter Information – THIS INFORMATION IS NOT SENT TO CDC
1. Reporter Name:

2. Date Reported:
____/ ____/ ____

_____________________________________

C. Enrollment Information
1. Case Classification:
 Prospective Surveillance

2. Admission Type:
3. County:
4. State:
 Discharge Audit
 Hospitalization
 Observation Only
 Years
 Days (if < 1 month)
 Male
5. Case Type:
6. Date of Birth: 7. Age:
8. Sex:
 Pediatric
 Adult
____/ ____/ ____ _________
 Months (if < 1 yr)
 Female
 Black or African American
 Asian/Pacific Islander
9. Race:  White
10. Ethnicity:  Hispanic or Latino
 American Indian or Alaska Native  Multiracial
 Not specified
 Non-Hispanic or Latino
 Not Specified
11. Hospital ID Where
Patient Treated:

11a. Admission Date:

___________

12. Was patient transferred from another hospital?

 Yes

_____/ _____/ _____
 No

_____/ _____/ _____

12b. Transfer Hospital Admission Date:

13. Where did patient reside at the time of hospitalization?

 Unknown

11b. Discharge Date:
12a. Transfer Hospital ID:

_____/ _____/ _____
_____________

_____/ _____/ _____

12c. Transfer Date:
Indicate TYPE of residence.

 Private residence

 Rehabilitation facility

 Group home/Retirement home

 Assisted living/Residential care

 Homeless/Shelter

 Nursing home

 Unknown

 Other, specify: _____________________

13a. If resident of a facility, indicate NAME of facility: ____________________________________________________________

D. Influenza Testing Results
1. Test 1:

 Rapid

 RT-PCR

 Viral Culture

1a. Result:

 Flu A (not subtyped)

 Flu B

 Flu A & B

 Flu A/B (Not Distinguished)

 2009 H1N1

 H1, Seasonal

 H1, Unspecified

 H3

 Negative

 Unknown

 Other, specify: _________________________________________________

1b. Specimen collection date: ___/___/ ___
 RT-PCR

 Serology

 Fluorescent Antibody

1c. Testing facility ID: __________________

 Viral Culture

 Flu A, Unsubtypable
1d. Specimen ID: _______________________

2. Test 2:

 Rapid

2a. Result:

 Flu A (not subtyped)

 Flu B

 Flu A & B

 Flu A/B (Not Distinguished)

 2009 H1N1

 H1, Seasonal

 H1, Unspecified

 H3

 Negative

 Unknown

 Other, specify: _________________________________________________

2b. Specimen collection date: ___/___/ ___
 RT-PCR

 Serology

 Method Unknown/Note Only

 Fluorescent Antibody

2c. Testing facility ID: __________________
 Viral Culture

 Flu A, Unsubtypable
2d. Specimen ID: _______________________

3. Test 3:

 Rapid

3a. Result:

 Flu A (not subtyped)

 Flu B

 Flu A & B

 Flu A/B (Not Distinguished)

 2009 H1N1

 H1, Seasonal

 H1, Unspecified

 H3

 Negative

 Unknown

 Other, specify: _________________________________________________

3b. Specimen collection date: ___/___/ ___
 RT-PCR

 Serology

 Method Unknown/Note Only

 Fluorescent Antibody

3c. Testing facility ID: __________________
 Viral Culture

 Serology

 Method Unknown/Note Only
 Flu A, Unsubtypable

3d. Specimen ID: _______________________

4. Test 4:

 Rapid

4a. Result:

 Flu A (not subtyped)

 Flu B

 Flu A & B

 Fluorescent Antibody

 Flu A/B (Not Distinguished)

 Method Unknown/Note Only

 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 (0920-0978).

1

Case ID:

Form Approved
OMB No. 0920-0978
Exp. Date. 08/31/2016

1 3 1 4

2013-14 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form
E. Admission and Patient History
1. Was patient discharged from any hospital within one week prior to the current admission date?

 Yes

 No

2. Acute conditions at admission (Check all that apply):
 Acute respiratory illness
 Asthma and/or COPD exacerbation
 Fever
 Other respiratory or cardiac conditions
 Other, neither respiratory nor cardiac conditions
 Unknown
____/ ____/ ____
3. Date of onset of acute respiratory symptoms:
3a. If no respiratory symptoms, date of onset of acute illness resulting in hospitalization: ____/ ____/ ____
 Inches
 Cm
4. Body Mass Index:
5. Height:
6. Weight:
 Unknown
 Unknown
7. Smoker:

 Current

 Former

 No/Unknown

8. Alcohol abuse:

 Current

9. Did patient have any of the following pre-existing medical conditions? Check all that apply.
9a Asthma/Reactive Airway Disease

 Yes

 No/Unknown

 Yes  No/Unknown
9b. Chronic Lung Disease
 Cystic fibrosis
 Emphysema/COPD
 Other, specify________________________________________
 Yes  No/Unknown
9c. Chronic Metabolic Disease
 Diabetes
 Thyroid dysfunction
 Other, specify________________________________________
 Yes  No/Unknown
9d. Blood disorders/Hemoglobinopathy
 Sickle cell disease
 Splenectomy/Asplenia
 Thrombocytopenia
 Other, specify ________________________________________
 Yes  No/Unknown
9e. Cardiovascular Disease
 Atherosclerotic cardiovascular disease (ASCVD)
 Cerebral vascular incident/Stroke
 Congenital heart disease
 Coronary artery disease (CAD)
 Heart failure/CHF
 Other, specify _______________________________________
 Yes  No/Unknown
9f. Neuromuscular disorder
 Duchenne muscular dystrophy
 Muscular dystrophy
 Multiple sclerosis
 Mitochondrial disorder
 Myasthenia gravis
 Other, specify: _____________________________________
9g. Neurologic disorder
 Cerebral palsy
 Cognitive dysfunction
 Dementia
 Developmental delay
 Down syndrome
 Plegias/Paralysis
 Seizure/Seizure disorder

 Yes

 No/Unknown

 Pneumonia
 Unknown
 Unknown
 Lbs
 Kg
 Unknown

 Former
 Yes

9h History of Guillain-Barré Syndrome

 Unknown

 No/Unknown

 No
 Yes

 Unknown
 No/Unknown

 Yes  No/Unknown
9i. Immunocompromised Condition
 AIDS or CD4 count < 200
 Cancer diagnosis in last 12 months
 Complement deficiency
 HIV Infection
 Immunoglobulin deficiency
 Immunosuppressive therapy
 Organ transplant
 Stem cell transplant (e.g., bone marrow transplant)
 Steroid therapy (taken within 2 weeks of admission)
 Other, specify________________________________________
 Yes  No/Unknown
9j. Renal Disease
 Chronic kidney disease/chronic renal insufficiency
 End stage renal disease/Dialysis
 Glomerulonephritis
 Nephrotic syndrome
 Other, specify _______________________________
 Yes  No/Unknown
9k. Other
 Liver disease (e.g., cirrhosis, chronic hepatitis, hepatitis C)
 Morbidly obese (ADULTS ONLY)
 Obese
 Pregnant
 If pregnant, specify gestational age in weeks: ___________
 Unknown gestational age
 Post-partum (two weeks or less)
 Other, specify ________________________________________
______________________________________________________
______________________________________________________

9l. PEDIATRIC CASES ONLY
 Yes  No/Unknown
Abnormality of upper airway
 Yes  No/Unknown
History of febrile seizures
 Yes  No/Unknown
Long-term aspirin therapy
 Yes  No/Unknown
Premature
(gestation age < 37 weeks at birth for patients < 2yrs)
If yes, specify gestation age at birth in weeks: ________________
 Unknown gestational age at birth

 Other, specify: _____________________________________

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Case ID:

1 3 1 4

Form Approved
OMB No. 0920-0978
Exp. Date. 08/31/2016

2013-14 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form
F. Intensive Care Unit and Interventions
1. Was the patient admitted to an intensive care unit (ICU)?
1a. Number of ICU Admissions _________
 Unknown
 Unknown
1b. Date of first ICU Admission: ____/____/____

 Yes
1c. Date of first ICU Discharge

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

 No

 Unknown

____/____/____
 Yes  No
 Yes  No

 Unknown
 Unknown
 Unknown

G. Bacterial Pathogens – Sterile or respiratory site only
 Yes  No
 Unknown
1. Were any bacterial culture tests performed with a collection date within three days of admission?
 Yes  No
 Unknown
2. If yes, was there a positive culture for a bacterial pathogen?
____/
____/
____
3a. If yes, specify Pathogen 1: ___________________________________________ 3b. Date of culture:
 Blood
 Cerebrospinal fluid (CSF)
 Bronchoalveolar lavage (BAL)
3c. Site where pathogen identified:
 Sputum
 Pleural fluid
 Endotracheal aspirate
 Other, specify: _________________
 Methicillin resistant (MRSA)  Methicillin sensitive (MSSA)
 Sensitivity unknown
3d. If Staphylococcus aureus, specify:
 Yes
 No
 Unknown
3e. If Haemophilus influenzae, specify if type B:
B
C
Y
 Other, specify: ____________  Unknown
3f. If Neisseria meningitidis, specify serogroup:
____/ ____/ ____
4a. Specify Pathogen 2: ________________________________________________ 4b. Date of culture:
 Blood
 Cerebrospinal fluid (CSF)
 Bronchoalveolar lavage (BAL)
4c. Site where pathogen identified:
 Sputum
 Pleural fluid
 Endotracheal aspirate
 Other, specify: ______________________
 Methicillin resistant (MRSA)
 Methicillin sensitive (MSSA)
 Sensitivity unknown
4d. If Staphylococcus aureus, specify:
 Yes
 No
 Unknown
4e. If Haemophilus influenzae, specify if type B:
B
C
Y
 Other, specify: ____________  Unknown
4f. If Neisseria meningitidis, specify serogroup:

H. Viral Pathogens
 Yes
1. Was patient tested for any of the following viral respiratory pathogens within 3 days of admission?
1a. Respiratory syncytial virus/RSV
 Yes, positive
 Yes, negative
 Not tested/Unknown
1b. Adenovirus
 Yes, positive
 Yes, negative
 Not tested/Unknown
1c. Parainfluenza 1
 Yes, positive
 Yes, negative
 Not tested/Unknown
1d. Parainfluenza 2
 Yes, positive
 Yes, negative
 Not tested/Unknown
1e. Parainfluenza 3
 Yes, positive
 Yes, negative
 Not tested/Unknown
1f. Human metapneumovirus
 Yes, positive
 Yes, negative
 Not tested/Unknown
1g. Rhinovirus
 Yes, positive
 Yes, negative
 Not tested/Unknown
1h. Other, specify: ______________  Yes, positive
 Yes, negative
 Not tested/Unknown

 No
 Unknown
Date: ____/____/____
Date: ____/____/____
Date: ____/____/____
Date: ____/____/____
Date: ____/____/____
Date: ____/____/____
Date: ____/____/____
Date: ____/____/____

I. Influenza Treatment
 Yes  No
 Unknown
1. Did patient receive antiviral medication treatment for influenza during the course of this illness?
 Oseltamivir (Tamiflu)
 Zanamivir (Relenza)
 Other, specify: _______________________________
2a. Treatment 1:
 Amantadine (Symmetrel)
 Rimantadine (Flumadine)
 Unknown
 Intravenous (IV)  Inhaled
 Unknown
2b. Method of Administration:  Oral
2c. Start Date: ___/____/____ 2d. End Date: ____/____/____ 2e. Dose _________________
2f. Frequency: _________________
 Start Date Unknown
 End Date Unknown
 Dose Unknown
 Frequency Unknown
 Oseltamivir (Tamiflu)
 Zanamivir (Relenza)
 Other, specify: _______________________________
3a. Treatment 2:
 Amantadine (Symmetrel)
 Rimantadine (Flumadine)
 Unknown
 Oral
 Intravenous (IV)  Inhaled
 Unknown
3b. Method of Administration:
3c. Start Date: ___/____/____ 3d. End Date: ____/____/____ 3e. Dose _________________
3f. Frequency: _________________
 Start Date Unknown
 End Date Unknown
 Dose Unknown
 Frequency Unknown
 Oseltamivir (Tamiflu)
 Zanamivir (Relenza)
 Other, specify: _______________________________
4a. Treatment 3:
 Amantadine (Symmetrel)
 Rimantadine (Flumadine)
 Unknown
 Oral
 Intravenous (IV)  Inhaled
 Unknown
4b. Method of Administration:
4c. Start Date: ___/____/____ 4d. End Date: ____/____/____ 4e. Dose _________________
4f. Frequency: _________________
 Start Date Unknown
 End Date Unknown
 Dose Unknown
 Frequency Unknown
 Oseltamivir (Tamiflu)
 Zanamivir (Relenza)
 Other, specify: _______________________________
5a. Treatment 4:
 Amantadine (Symmetrel)
 Rimantadine (Flumadine)
 Unknown
 Oral
 Intravenous (IV)  Inhaled
 Unknown
5b. Method of Administration:
5c. Start Date: ___/____/____ 5d. End Date: ____/____/____ 5e. Dose _________________
5f. Frequency: _________________
 Start Date Unknown
 End Date Unknown
 Dose Unknown
 Frequency Unknown
6. Additional Treatment Comments:

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Case ID:

1 3 1 4

Form Approved
OMB No. 0920-0978
Exp. Date. 08/31/2016

2013-14 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form
J. Chest Radiograph – Based on radiology report only
 Yes
 No
 Unknown
1. Was a chest x-ray taken within 3 days of admission?
 Yes
 No
 Unknown
2. Were any of these chest x-rays abnormal?
____/____/____
2a. Date of first abnormal chest x-ray:
2b. For first abnormal chest x-ray, please check all that apply:
 Report not available
 Consolidation
 Interstitial infiltrate
 Air space density/opacity
 Atelectasis
 Pleural effusion/empyema
 Bronchopneumonia/pneumonia
 Cavitation
 Lobar (NOT interstitial) infiltrate
 Cannot rule out pneumonia
 ARDS (acute respiratory distress syndrome)
 Other
2c. Please specify location for bronchopneumonia/pneumonia/consolidation/lobar infiltrate/air space density/opacity:
 Single lobar
 Multiple lobar (unilateral)
 Multiple lobar (bilateral)
 Unknown

K. Discharge Summary
1. Did the patient have any of the following diagnoses at discharge (check all that apply)?
Pneumonia
Guillain-Barré
syndrome
Acute encephalopathy/
encephalitis
Seizures

 Yes

 No

 Unknown

Stroke (CVI)

 Yes

 No

 Unknown

 Yes

 No

 Unknown

Acute myocarditis

 Yes

 No

 Unknown

 Yes

 No

 Unknown

 Yes

 No

 Unknown

 Yes

 No

 Unknown

Acute respiratory distress syndrome
(ARDS)
Bronchiolitis

 Yes

 No

 Unknown

Reye’s syndrome

 Yes

 No

 Unknown

Hemophagocytic syndrome

 Yes

 No

 Unknown

 Alive
2. What was the outcome of the patient?
2a. If discharged alive, please indicate to where:
 Home
 Other hospital
 Rehabilitation Facility
 Group home/Retirement home
 Home with Services
 Nursing home

 Deceased

 Unknown

 Hospice/Home hospice
 Homeless/Shelter
 Assisted living/Residential Care
 Unknown
 Other, specify: _____________________
3. If patient was pregnant on admission, indicate pregnancy status at discharge:  Still pregnant  No longer pregnant  Unknown
3a. 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
4. Additional notes regarding discharge: _____________________________________________________________________________________

L. ICD-9 or ICD-10 Discharge Diagnoses – To be recorded in order of appearance
Version:

 ICD-9

 ICD-10

1.

4.

7.

2.

5.

8.

6.

9.

3.

M. Vaccination History
 Yes  No
 Unknown
1. Did patient receive the influenza vaccine for the current influenza season?
Specify vaccination status and date(s) by source:
 Yes  Yes, specific date unknown
 No  Unknown  Not Checked
2. Medical Chart
1) ___/___/___
 Date Unknown
2) (Pediatrics Only) ___/___/___
 Date Unknown
2a. If yes, specify dosage date information:
 Yes  Yes, specific date unknown
 No  Unknown  Not Checked
3.Vaccine Registry
1) ___/___/___
 Date Unknown
2) (Pediatrics Only) ___/___/___
 Date Unknown
3a. If yes, specify dosage date information:
 Yes  Yes, specific date unknown
 No  Unknown  Not Checked
4. Primary Care Provider / Long-term Care Facility
1) ___/___/___
 Date Unknown
2) (Pediatrics Only) ___/___/___
 Date Unknown
4a. If yes, specify dosage date information:
 Yes  Yes, specific date unknown
 No  Unknown  Not Checked
5. Interview:
 Patient
 Proxy
1) ___/___/___
 Date Unknown
2) (Pediatrics Only) ___/___/___
 Date Unknown
5a. If yes, specify dosage date information:
 Yes  Yes, specific date unknown
 No  Unknown  Not Checked
6. Other, specify: ______________________
1) ___/___/___
 Date Unknown
2) (Pediatrics Only) ___/___/___
 Date Unknown
6a. If yes, specify dosage date information:
 Yes
 No
 Unknown
7. If patient < 9 years, did patient receive any seasonal influenza vaccine in previous seasons?

N. Miscellaneous
1. Case Finding:

 Hospital Log

 Laboratory List

 Discharge Database

 Reportable Disease

 Other, specify: __________

2. Additional Comments:

4