Antiviral Resistant Influenza Infection Case Report Form

Antiviral-Resistant Influenza Infection Case Report Form
Form Approved
OMB No. 0920-0004
CDC ID (CDC use only): _______________

FAX COMPLETED FORM TO: 404-639-3866
I. Specimen Information
State Lab Specimen ID
Specimen Collection State
Patient County of residence
Patient State of residence
Oseltamivir resistance

_______________
_______________
_______________
_______________
 Yes  No  Unk

Reason for Antiviral Resistance Test:
 Requested for Clinical Indication
 Surveillance
 Other _________________
Date of Specimen Collection:
__ __/ __ __/ __ __ __ __

Specimen Type:
 Nasopharyngeal (NP) Swab
 Nasal swab
 Oropharyngeal Swab
 Bronchoalveolar Lavage
 Other___________________

II. Basic Information If information is from patient interview please READ:: I’m going to ask you for some information about yourself
(your child) and your (the child’s) illness. To help you remember, I am going to tell you the date that your nose/ throat swab was taken
to test for flu (use specimen collection date in section I). Please feel free to look at a calendar to help you remember dates. I can wait
until you find one.
Age: __ __  yrs  months
Is sex known?
 Yes  No
Sex:  Male  Female
Is ethnicity known?
 Yes  No
Ethnicity:
 Hispanic or Latino
 Not Hispanic or Latino

Is race known? Yes  No
Race:
 American Indian/ Alaska
Native
 Asian or Pacific Islander
 Black or African American
 White
 Other __________

Illness History:
Date of illness onset:
__ __/ __ __/ __ __ __ __
Hospitalized for illness? Yes
No
Unknown

Patient Outcome:
 At Home
 At Extended Care Facility
 Currently Hospitalized
 Dead (Was it influenzarelated?
Yes  No 
Unknown)
 Unknown

III. Pre-existing Medical Conditions
Did a doctor ever tell you that you (your child) had any of
the following conditions? (Check all that apply)
 No underlying conditions
 Diabetes Mellitus
 Chronic kidney disease
 Asthma
 Chronic lung disease (non-asthma), specify_______
 Neurologic/neuromuscular disease

 Immunosuppressive condition (complete section X)
 Chronic Heart Disease, specify: ___________________
 Chronic Liver Disease, specify: ___________________
 Morbid obesity: Height _______ Weight _______
 Other Condition, specify: ___________________
If female aged >16 years, were you pregnant at time of specimen
collection:  Yes  No  Unknown Trimester ______

IV. Hospitalized Patient Information (skip to section V if patients is not hospitalized)
Date of hospital admission: __ __/ __ __/ __ __ __ __

Reason for Hospital Admission:  Respiratory Illness

Date of hospital discharge: __ __/ __ __/ __ __ __ __
Where was the patient discharged to?  Other hospital  Home 
Hospice  Rehabilitation facility  Long term care facility  Other
 Other, specify:

During hospitalization, was patient:
In Intensive Care Unit?
 Yes  No  Unknown

Mechanically Ventilated?
 Yes  No Unknown

On Vasopressors?
 Yes  No  Unknown

Renal Failure requiring Dialysis?
 Yes  No  Unknown

V. Influenza Antiviral Medication History
Received influenza antiviral medications including oseltamivir (Tamiflu®) or zanamivir (Relenza®)?
 Yes  No (skip to section VI)  Unknown (skip to section VI)
If yes, Please check all below that apply:

Public reporting burden of this collection of information is estimated to average 30 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 (0920‐0004).

 Oseltamivir (Tamiflu)
Dose:
 75mg  Other _______
Frequency:  QD  BID  Other _____
Indication:  Treatment  Prevention
Location:
 Outpatient  Inpatient
Start Date: __ __/ __ __/ __ __ __ __
End Date: __ __/ __ __/ __ __ __ __

 Zanamivir (Relenza)
Dose:
 10mg
 Other _______
Route:
 Inhaled  IV (experimental)
Frequency:  QD  BID  Other _____
Indication:  Treatment  Prevention
Location:
 Outpatient  Inpatient
Start Date: __ __/ __ __/ __ __ __ __
End Date: __ __/ __ __/ __ __ __ __

 Additional/other Agent
Name:
_______________________
Dose:
_______________________
Route:
 Oral  IV  Inhaled
Frequency:  BID
 Other _______
Indication:  Treatment  Prevention
Location:
 Outpatient  Inpatient
Start Date: __ __/ __ __/ __ __ __ __
End Date: __ __/ __ __/ __ __ __ __
 Yes  No  Unknown

Patient finished all of the pills (or suspension)?

Information on antiviral treatment is from (check all that apply)
 inpatient medical record  outpatient medical record  dispensing pharmacy  self-report
Comments about antiviral therapy: (e.g. other courses of antiviral treatment, reasons for poor compliance, etc.)

VI. Influenza Vaccine History
Did you (your child) receive the influenza vaccine this year?

 Yes  No  Unknown

VII. Clinical Illness [Read to patient: I am going to ask you some questions about your (your child’s) illness. Please feel free to look at
the calendar to help you remember.]
1. Did you (your child) have a fever or feel feverish when you (he/she) had flu?
 Yes
 No (skip to Q2)
 DK (skip to Q2)
1a. How many days did you (your child) have fever?
______ day(s)
1b. Did you take your (your child’s) temperature?
 Yes
 No (skip to Q2)  DK (skip to Q2)
1c. What was the highest temperature that you recorded? __________
2. Did you (your child) have a new cough with your flu illness?
 Yes
 No  DK
3. Did you (your child) have achy muscles or joints with your flu illness?
 Yes
 No  DK
4. Did you have diarrhea (loose stools three times a day) with your flu illness?  Yes
 No  DK
5. Did you have vomiting with your flu illness?
 Yes
 No  DK
6. On what date did you first seek medical care for the flu illness? __ __ / __ __ / __ __ __ __
7. Did you need to return for additional care after that visit?
 Yes
 No
 N/A
8. How many days did your (your child’s) flu illness last?
_____ day(s)
9. How many days until you felt (your child felt or acted) back to your normal self? _____ day(s)
If the patient is a child or a student ask the following questions. If not, skip to next the question.
 Yes
 No (skip to Q11)
 DK (skip to Q11)
10. Did you (your child) miss any days of school due to the flu illness?
10a. How many days did you (your child) miss? _____ days
If the patient is an adult (>=18 years of age) ask the following question. If not, skip to the next section.
11. Do you have a job outside your home?
 Yes
 No (skip to section VIII)
 DK (skip to section VIII)
11a. Did you miss any days of work?
 Yes
 No (skip to section VIII)
 DK (skip to section VIII)
11b. How many days did you miss?
_____ day(s)
VIII. Transmission History [Read to patient: I’m going to ask some questions about others in your home who may have been ill and
travel.]
 Single Family House (1 housing unit in building)
 Multi-Family Housing ( > 1 unit in building)
 Facility (hospital, long term care, nursing home, jail, etc)
 University Dorm or boarding school
 Other, specify: _____________________________

1.

At the time you (your child) became ill, where did you
reside?

2.

How many people live in your household? [a household is defined as the place where you regularly sleep and eat]

3.

During the week before illness, did anyone else in the household have flu or a respiratory illness?
If Yes, Did anyone else other than you in the household get a diagnosis of flu?

4.

During the week before illness, did anyone else in the
household receive any antiviral medications?

_____

 Yes  No  Unknown
If yes, how many? ________
 Yes  No  Unknown
If yes, how many? ________

 Yes (  for treatment  for prevention)
 No

 Unknown
 Tamiflu Relenza Unknown Other specify______

If yes, What was the name of the antiviral agent?
5.

 Yes

Did you travel outside of your typical residence area during the 7 days prior to illness?

 No

 Unknown

If yes, Where did you travel to? Country__________ state______ city/town_____________
Dates of travel? __ __/ __ __/ __ __ __ __ to __ __/ __ __/__ __ __ __
If the patient is a child, university student or living in a facility (e.g. LTCF), ask the following questions, if not, skip to the next
section.
6. Were others at your (your child’s) school/residency also sick at the same time as your (the child’s) flu illness?

 Yes

 No

 DK

If yes, where do you (your child) go to school/ reside?

________________________________

IX. Additional Comments

Sender Information
First Name:

Last Name:

Institution Name:

Date of Survey Completion: __ __/ __ __/ __ __ __ __

Email Address:

Telephone Number:

X. Immunosuppression Details (check all that apply)

Specify type(s)

 Solid Tumor
Malignancy:

 Hematologic
Malignancy:

 Receipt of Stem
Cell Transplant

 Receipt of Solid
Organ Transplant

 Autoimmune
Disorder











 Other condition (Lupus, Rheumatoid Arthritis, Crohns, etc) Specify Type (s):

 HIV/AIDS

IF ANTIVIRAL USE IS SELF REPORTED AND NOT VERIFIED BY MEDICAL OR PHARMACY RECORDS: Thank you very much for
taking the time to answer our questions. We would like to contact the health care provider you (your child) saw during the time of your
illness to get more information on the treatment you received. Would it be OK for us to contact your doctor or health care provider
(please circle selection)?
Y
N
Unsure
If yes, Please provide us with his or her information:
Name of facility and health care provider: __________________________________
Phone number: __________________________________
Case information to be collected from the health care provider
Hello, my name is ___________ and I am calling from the state (or local) public health department in collaboration with the Centers for
Disease Control and Prevention. I am calling to collect some information on a patient that was seen by you on about ___/___/___. The
patient’s name was ____________ and date of birth was ___/___/___. We are collecting information on patients with influenza
infection and would like to determine whether each case received antiviral treatment. I would like to ask you a few questions about this
person’s illness and any treatment with influenza antiviral medication, including Tamiflu.
Were antiviral agents prescribed to the patient for treatment (please circle selection)?

Y

If yes, what medication was prescribed?

Length of
Prescribed
Course (days)
_______
_______
_______

Dose
(mg)

i.
Oseltamivir (Tamiflu)
_____
ii.
Zanamivir (Relenza)
_____
iii.
Other
_____
Thank you very much for taking the time to answer our questions.

Date of
Treatment Onset
___/___/___
___/___/___
___/___/___

N

Don’t Know