Acute Respiratory Infection and Influenza Surveillance Form

U.S. Department of Health and Human Services (HHS) OMB Control # 0920-XXXX

Centers for Disease Control and Prevention (CDC) Expiration Date XX/XX/XXXX

Wisconsin Influenza and Acute respiratory Infection Surveillance

Acute Respiratory Infection and Influenza Surveillance Form

School ID: _______________

Participant ID: ____________

Name: ___________________

DOB: ___ / ___ / ___

Criteria for patient selection and testing

• symptom onset within 4 days

• any two of the following

  

  ORegon CHild Absenteeism due to Respiratory Disease Study

  
  

  • rhinorrhea

  • nasal congestion

  • sneezing

  • sore throat

  • cough

  • fever

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Days between illness onset and today’s visit: ____ days

Exposure to a similar illness 1-3 days prior to ARI onset? Yes No

Recent Travel? Yes No Recent Exposuree to Farm Animals? Yes No

Severity of Illness (circle): Mild Moderate Severe

Ethnicity:

-- Hispanic or Latino

-- Not Hispanic or Latino

Race: American Indian or Alaska Native Asian Black or African American

Native Hawaiian or Other Pacific Islander White

Measured Temperature ___ ^oF Antipyretic use within the last 6 hours? Yes No

Symptoms (circle all that are present):

Fever Chills Cough Wheezing Runny Nose

Sore Throat Malaise Myalgia Arthralgia Nasal Congestion

Headache Ear Pain Anorexia Vomiting Abdominal Pain

Diarrhea Conjunctivitis Other: ___________________________________

Influenza antiviral treatment for this illness prior to this visit? Yes No

Seasonal influenza vaccine prior to this illness? Yes No

Indicate Specimen Type(s) for PCR testing: nasopharynx posterior pharynx

- - - - - - - - - - ITEMS BELOW THIS LINE FOR LABORATORY ONLY - - - - - - - -

Sofia Result:  flu A  flu B  both  negative  invalid

Sample Code: _ORCHARDS_ - _____ - ____ - ______

site week staff sample ___________________________________________________________________________

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. An agency may not conduct or sponsor this survey, 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-XXXX.