Adenovirus Typing Report Form | |||||||||||||
Form OMB No. 0920-0004 |
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Reporting Lab : | Report Date: | ||||||||||||
Positive Test Results | |||||||||||||
Age (# Only) | Age Type (Months or Years) | Sex (M/F/U) | State of Residence (see codes--2rd sheet) | AdV Group (A-F) | AdV Type | Source Specimen (see legend--far right) | Specimen Collection Date (mm/dd/yyyy) | Hospitalized (Y/N/U) | Outbreak(Y/N/U) | Specimen Legend | |||
1 | NP/OP swab | ||||||||||||
Outbreak Type | 2 | NP/OP wash | |||||||||||
(see legend--far right) | 3 | Sputum | |||||||||||
4 | Tracheal Aspirate | ||||||||||||
5 | Bronchoalveolar Lavage | ||||||||||||
6 | Pleural Fluid | ||||||||||||
7 | Ocular Swab | ||||||||||||
8 | Other | ||||||||||||
9 | Unknown | ||||||||||||
Outbreak Type | |||||||||||||
1 | Hospital | ||||||||||||
2 | School | ||||||||||||
3 | Daycare | ||||||||||||
4 | Long Term Care Facility | ||||||||||||
5 | Military | ||||||||||||
8 | Other (specify) _______ | ||||||||||||
9 | Unknown | ||||||||||||
Date of Report | Reporting Official | Title | |||||||||||
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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0004). | |||||||||||||
CDC XXXX Rev.01/2014 |
CODE | ABBR | STATENAME |
1 | AL | ALABAMA |
2 | AK | ALASKA |
4 | AZ | ARIZONA |
5 | AR | ARKANSAS |
6 | CA | CALIFORNIA |
8 | CO | COLORADO |
9 | CT | CONNECTICUT |
10 | DE | DELAWARE |
11 | DC | DISTRICT OF COLUMBIA |
12 | FL | FLORIDA |
13 | GA | GEORGIA |
15 | HI | HAWAII |
16 | ID | IDAHO |
17 | IL | ILLINOIS |
18 | IN | INDIANA |
19 | IA | IOWA |
20 | KS | KANSAS |
21 | KY | KENTUCKY |
22 | LA | LOUISIANA |
23 | ME | MAINE |
24 | MD | MARYLAND |
25 | MA | MASSACHUSETTS |
26 | MI | MICHIGAN |
27 | MN | MINNESOTA |
28 | MS | MISSISSIPPI |
29 | MO | MISSOURI |
30 | MT | MONTANA |
31 | NE | NEBRASKA |
32 | NV | NEVADA |
33 | NH | NEW HAMPSHIRE |
34 | NJ | NEW JERSEY |
35 | NM | NEW MEXICO |
36 | NY | NEW YORK |
37 | NC | NORTH CAROLINA |
38 | ND | NORTH DAKOTA |
39 | OH | OHIO |
40 | OK | OKLAHOMA |
41 | OR | OREGON |
42 | PA | PENNSYLVANIA |
44 | RI | RHODE ISLAND |
45 | SC | SOUTH CAROLINA |
46 | SD | SOUTH DAKOTA |
47 | TN | TENNESSEE |
48 | TX | TEXAS |
49 | UT | UTAH |
50 | VT | VERMONT |
51 | VA | VIRGINIA |
53 | WA | WASHINGTON |
54 | WV | WEST VIRGINIA |
55 | WI | WISCONSIN |
56 | WY | WYOMING |
60 | AS | AMERICAN SAMOA |
64 | FM | FEDERATED STATES OF MICRONESIA |
66 | GU | GUAM |
69 | MP | NORTHERN MARIANA ISLANDS |
70 | PW | PALAU |
72 | PR | PUERTO RICO |
74 | UM | U.S. MINOR OUTLYING ISLANDS |
78 | VI | VIRGIN ISLANDS |
99 | UNK | UNKNOWN |
File Type | application/vnd.ms-excel |
Author | AHL4 |
Last Modified By | CDC User |
File Modified | 2014-05-08 |
File Created | 2001-09-28 |