WHO Fax Form

P

Form Approved

OMB No. 0920-0004

Exp. Date 6/30/2013

lease fax report to 1-888-232-1322 (No cover sheet is needed)

WHO COLLABORATING CENTER FOR INFLUENZA

INFLUENZA VIRUS SURVEILLANCE

Lab ID Number

L aboratory / Report for week ending ____/____/____

(City) (State) Mo. Day Yr.

Patient's age in years	<1	1-4	5-24	25-44	45-64	65	Unk
No. of specimens tested for respiratory viruses

No. influenza A(H1N1) (SEASONAL!)
No. influenza A(H3N2)
No. influenza 2009 influenza A (H1N1)
No. influenza A, not subtyped*
No. influenza A, unable to be subtyped**
No. influenza B*

* Subtyping NOT ATTEMPTED

** Subtyping attempted but negative for seasonal H1, seasonal H3, and 2009 influenza A (H1N1).

• If you have no tests or results to report for a week, please fax a form listing the laboratory name and week ending date, but leave the rest of the form blank.

• If you wish to revise a previous report (e.g., report isolates as “influenza A, subtype unknown” and subsequently subtype the isolates), please indicate the changes on a copy of the form on which the isolates were initially reported, listing the original week ending date. Clearly mark the copy as a revised report and fax it to us.

P lease call us about unusual isolates: (404-639-3591)

Comments:

A weekly influenza activity report is available on the internet at http://www.cdc.gov/flu/weekly/ .

Public reporting burden of this collection of information is estimated to average 10 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).