Acute Respiratory Infection and Influenza Surveillance Form

Information Collection on Cause-Specific Absenteeism in Schools

Att C5- Univ of Wisconsin - Acute Respiratory Infection and Influenza Surveillance Form

Acute Respiratory Infection and Influenza Surveillance Form

OMB: 0920-1039

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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


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Wisconsin Influenza and Acute respiratory Infection Surveillance

Acute Respiratory Infection and Influenza Surveillance Form


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School ID: _______________

Participant ID: ____________

Name: ___________________

DOB: ___ / ___ / ___

Criteria for patient selection and testing

  • symptom onset within 4 days

  • any two of the following

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    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.

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