Respiratory Illness Cluster Case Investigation

UAC Respiratory Disease Cluster
Case Investigation Form

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

State: _____ Date reported to health department: ___/___/_____ (MM/DD/YYYY) Date interview completed: ___/___/_____ (MM/DD/YYYY)
Alien Number:_______________________________________________ CDC Lab ID: ________________________________________________
Demographic Information
1. Date of birth: _____/_____/_____ (MM/DD/YYYY)
2. Country of origin: ____________________________ Region: ____________________________ City/town: ___________________________
3. Estimated travel time from country of origin to US border: ___________ days weeks months
4. Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
5. Sex:
Male
Female
Symptoms and Care Seeking
6. What date did symptoms associated with this illness start? _____/_____/_______ (MM/DD/YYYY)
7. Were symptoms present at the CBP Processing Center?
Yes
No
Unknown
8. Were symptoms present at a CBP facility before transfer to the processing center?
Yes, which facility? _______________ No Unknown
9. During this illness, did the patient experience any of the following?
Symptom
Symptom Present?
Symptom
Symptom Present?
Fever (highest temp _________ oF)
Yes
No
Unk Shortness of breath
Yes
No
Unk
If fever present, date of onset ___/___/____ (MM/DD/YYYY)
Vomiting
Yes
No
Unk
Felt feverish
Yes
No
Unk Diarrhea
Yes
No
Unk
If felt feverish, date of onset ___/___/____ (MM/DD/YYYY)
Eye infection/redness
Yes
No
Unk
Cough
Yes
No
Unk Rash
Yes
No
Unk
Sore Throat
Yes
No
Unk Fatigue
Yes
No
Unk
Muscle aches
Yes
No
Unk Seizures
Yes
No
Unk
Headache
Yes
No
Unk Back pain
Yes
No
Unk
Abdominal pain
Yes
No
Unk Other, specify
Yes
No
Unk
10. Does the patient still have symptoms?
Yes (skip to Q.12)
No
Unknown (skip to Q.12)
11. When did the patient feel back to normal? _____/_____/_____ (MM/DD/YYYY)
12. Did the patient receive any medical care for the illness?
Yes
No (skip to Q.14)
Unknown (skip to Q.14)
13. Where and on what date did the patient seek care (check all that apply)?
CBP Processing Center date:_____/_____/_____ (MM/DD/YYYY)
Shelter medical service date:_____/_____/_____ (MM/DD/YYYY)
Urgent care date:_____/_____/_____ (MM/DD/YYYY)
Emergency room date:_____/_____/_____ (MM/DD/YYYY)
Other _______________________________ date:_____/_____/_____ (MM/DD/YYYY)
Unknown
14. Did the patient experience any other complications as a result of this illness?
Yes (please describe below)
No
Unknown
____________________________________________________________________________________________________________________
15. Does the patient have any preexisting medical conditions (e.g. problems with heart, lung)?
Yes (please describe below)
No
Unknown
____________________________________________________________________________________________________________________
Risk Factors
16. In the 7 days prior to illness onset, please list the locations/CPB facilities the patient has been (including international).
Location 1: Dates: _____/_____/_____ to _____/_____/_____ Country _____________ State ______ City/CPB facility__________________
Location 2: Dates: _____/_____/_____ to _____/_____/_____ Country _____________ State ______ City/CPB facility__________________
Location 3: Dates: _____/_____/_____ to _____/_____/_____ Country _____________ State ______ City/CPB facility__________________
17. Which dormitory was the patient in when symptomatic? ________ (dormitory 101-110)
18. Which bed number was the patient in when symptomatic? ___________
19. Does the patient know anyone who had fever, respiratory symptoms like cough or sore throat, or another respiratory illness like pneumonia in
the 7 days BEFORE the case patient’s illness onset?
Yes (please list those ill before the case patient in the table below)
No
Unknown
Sex
Date of
Contact name
Age
Comments
(M/F)
illness onset

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 (0920-1011.

UAC Respiratory Disease Cluster
Case Investigation Form
20. Any additional comments or notes?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Please review the patient’s medical record, patient testing results, and facility records to obtain the answers for the remainder of the form.
Clinical Course, Treatment, and Outcome
21. Date of identification by CBP: _____/_____/_____ (MM/DD/YYYY)
22. Date of arrival to CBP Processing Center: _____/_____/_____ (MM/DD/YYYY)
Nogales, AZ or
McAllen, TX
Other: ____________
23. Date of arrival to Baytown Shelter: _____/_____/_____ (MM/DD/YYYY)
24. Approximately how many children were in the patient’s dormitory at the shelter on the date of symptom onset? ______________
25. Were other persons in the same dormitory symptomatic in the 7 days prior to the illness onset in this patient?
Yes
No (skip to Q.27)
Unknown (skip to Q.27)
26. How many persons were ill? ____________________
27. Was the patient hospitalized for the illness?
Yes
No (skip to Q.36)
Unknown (skip to Q.36)
28. Date(s) of hospital admission? First admission date:___/___/____ (MM/DD/YYYY) Second admission date:___/___/____ (MM/DD/YYYY)
29. Was the patient admitted to an intensive care unit (ICU)?
Yes
No (skip to Q.31)
Unknown (skip to Q.31)
30. Date of ICU admission: ______/_____/_______ (MM/DD/YYYY) Date of ICU discharge: ______/_____/_______ (MM/DD/YYYY)
31. Did the patient receive mechanical ventilation / have a breathing tube?
Yes
No (skip to Q.33)
Unknown (skip to Q.33)
32. For how many days did the patient receive mechanical ventilation or have a breathing tube? ___________________ days
33. Was the patient discharged?
Yes
No (skip to Q.36)
Unknown (skip to Q.36)
34. Date(s) of hospital discharge? First discharge date:___/___/____ (MM/DD/YYYY) Second discharge date:___/___/____ (MM/DD/YYYY)
35. Where was the patient discharged?
NBVC Shelter
Family member
Permanent shelter
Other _________________________
Unknown
36. Did the patient have a new abnormality on chest x-ray or CAT scan?
No, x-ray or scan was normal
Yes, x-ray or scan detected new abnormality
No, chest x-ray or CAT scan not performed
Unknown
37. Did the patient receive a diagnosis of pneumonia?
Yes
No
Unknown
38. Did the patient receive a diagnosis of ARDS?
Yes
No
Unknown
39. Did the patient receive antimicrobials prior to becoming ill (within 2 weeks) or after becoming ill?
Yes, (please complete table below)
No
Unknown
Start date
End date
Total number of days
Dosage
Drug
(MM/DD/YYYY) (MM/DD/YYYY)
receiving antivirals
(if known)
Oseltamivir (Tamiflu)
mg
Zanamivir (Relenza)
mg
Azithromycin
mg
Levofloxacin
mg
Augmentin
mg
Penicillin
mg
Other antimicrobial_____________________
mg
Other antimicrobial_____________________
mg
Other antimicrobial_____________________
mg
40. Did the patient die as a result of this illness?
Yes, Date of death:_____/_____/_____ (MM/DD/YYYY)
No
Unknown

Appendix A: Case Investigation Form

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UAC Respiratory Disease Cluster
Case Investigation Form
Medical History -- Past Medical History and Vaccination Status
41. Were any of the following chronic medical conditions noted during patient interview or recorded on the patient’s medical record? Please specify
ALL conditions noted.

42.
43.
44.
45.
46.
47.
48.

a.

Asthma/reactive airway disease

Yes

No

Unknown

b.

Tuberculosis

Yes

No

Unknown (If YES, specify) _______________________________

c.

Other chronic lung disease

Yes

No

Unknown (If YES, specify) _______________________________

d.

Chronic heart or circulatory disease

Yes

No

Unknown (If YES, specify) _______________________________

e.

Diabetes mellitus

Yes

No

Unknown (If YES, specify) _______________________________

f.

Kidney or renal disease

Yes

No

Unknown (If YES, specify) _______________________________

g.

Non-cancer immunosuppressive condition

Yes

No

Unknown (If YES, specify) _______________________________

h.

Cancer chemotherapy in past 12 months

Yes

No

Unknown (If YES, specify) _______________________________

i.

Neurologic/neurodevelopmental disorder

Yes

No

Unknown (If YES, specify) _______________________________

j.

Cerebrospinal fluid leaks

Yes

No

Unknown (If YES, specify) _______________________________

k.

Chronic liver disease

Yes

No

Unknown (If YES, specify) _______________________________

l.

Sickle cell/other hemaglobinopathies

Yes

No

Unknown (If YES, specify) _______________________________

m. Congenital or acquired asplenia

Yes

No

Unknown (If YES, specify) _______________________________

n.

Yes

No

Unknown (If YES, specify weight/height) ___________________

Malnutrition

o. Other chronic diseases
Yes
No
Unknown (If YES, specify) _______________________________
Was patient pregnant or ≤6 weeks postpartum at illness onset?
Yes, pregnant (weeks pregnant at onset)________
Yes, postpartum (delivery date) ___/___/____ (MM/DD/YYYY)
No
Unknown
Does the patient currently smoke?
Yes
No
Unknown
Was the patient vaccinated against influenza in the past year?
Yes
No (skip to Q.47)
Unknown (skip to Q.47)
Month and year of influenza vaccination? Vaccination date 1:____/_____ (MM/YYYY) Vaccination date 2:____/_____ (MM/YYYY)
Type of influenza vaccine (check all that apply):
Inactivated (injection)
Live attenuated (nasal spray)
Unknown
Did the patient ever receive the pneumococcal vaccine?
Yes
No (skip to Q.49)
Unknown (skip to Q.49)
Month and year of pneumococcal vaccination? Vaccination date 1:____/_____ (MM/YYYY)

Specimen Testing Results
49. Was the patient tested for any pathogens?

 Yes (please complete table below)

 No

 Unknown

Positive Negative Not Tested/Unknown
Collection Date
CT Value
a. Influenza
____/____/______
___________________________



If influenza positive, specify subtype  H1N1pdm09  H3N2  A,subtype unknown  Influenza B  Other___________________  Unknown
b. Pneumococcus
____/____/______
___________________________



c. Respiratory syncytial virus/RSV
____/____/______
___________________________



d. Adenovirus
____/____/______
___________________________



e. Parainfluenza 1



____/____/______
___________________________
f. Parainfluenza 2



____/____/______
___________________________
g. Parainfluenza 3



____/____/______
___________________________
h. Human metapneumovirus



____/____/______
___________________________
i. Rhinovirus



____/____/______
___________________________
j. Coronavirus



____/____/______
___________________________
k. Other, specify: _________________
____/____/______
___________________________



l. Other, specify: __________________
____/____/______
___________________________



m. Other, specify: _________________
____/____/______
___________________________




Appendix A: Case Investigation Form

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UAC Respiratory Disease Cluster
Case Investigation Form

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Estado: _TX_ Fecha de reporte al Departamento de Salud: ___/___/___ (MM/DD/AAAA) Fecha de la entrevista: ___/___/_____ (MM/DD/AAAA)
Número de extranjería:_______________________________________________ CDC Lab ID: __________________________________________
Información Demográfica
1. Fecha de nacimiento: _____/_____/_____ (MM/DD/AAAA)
2. País de origen: ___________________Region:____________________Ciudad/Pueblo:_______________________________________
3. Tiempo de viaje estimado de país de origen a la frontera con EEUU: ________ días semanas meses
4. Etnia:
Hispano ó Latino
No Hispano ó Latino
5. Sexo:
Masculino
Femenino
Síntomas, Curso Clínico de la enfermedad, Tratamiento, Análisis de las muestras y Resultados
6. En qué fecha comenzaron los síntomas asociados con la enfermedad? _____/_____/_______ (MM/DD/AAAA) (VER CALENDARIO)
7. Los síntomas estaban presentes al llegar a la Base de la Patrulla de Frontera de los EEUU?
Si
No
No sabe
8. Los síntomas estaban presentes antes de llegar a la Base de la Patrulla de Frontera de los EEUU?
Si
No
No sabe, si dijo si
Cual?___________
9. Durante el curso de la enfermedad, el paciente manifestó alguno de los siguientes síntomas?
Síntoma
Presentó?
Síntoma
Presentó?
Fiebre (Temperatura más alta __ oF)
Si
No
No sabe Dificultad para respirar
Si
No
No sabe
Si presentó fiebre, fecha de inicio __/__/___(MM/DD/AAAA)
Vómitos
Si
No
No sabe
Se sintió afiebrado
Si
No
No sabe Diarrea
Si
No
No sabe
Si se sintió afiebrado, fecha de inicio__/__/__(MM/DD/AAAA) Infección en los ojos/Ojos rojos
Si
No
No sabe
Tos
Si
No
No sabe Salpullido
Si
No
No sabe
Dolor de garganta
Si
No
No sabe Fatiga
Si
No
No sabe
Dolor muscular ó de cuerpo
Si
No
No sabe Convulsiones
Si
No
No sabe
Dolor de cabeza
Si
No
No sabe Dolor de espalda
Si
No
No sabe
Dolor abdominal
Si
No
No sabe Otro, especificar
Si
No
No sabe
10. El paciente todavía tiene síntomas?
Si (Pasar a la pregunta Q.12)
No
No sabe (Pasar a la pregunta Q.12)
11. En qué fecha es que el paciente se siente sano nuevamente? _____/_____/_____ (MM/DD/AAAA)
12. Recibió el paciente la atención médica adecuada para tratar la enfermedad?
Si
No (Pasar a la pregunta Q.14)
No sabe (Pasar a la pregunta Q.14)
13. Dónde y en qué fecha es que el paciente solicita atención médica (marcar todas las que apliquen)?
Base de la Patrulla de Frontera de los EEUU fecha:_____/_____/_____ (MM/DD/AAAA)
Clínica de CASA HOGAR fecha:_____/_____/_____ (MM/DD/AAAA)
Clínica de urgencia fecha:_____/_____/_____ (MM/DD/AAAA)
Sala de emergencia fecha:_____/_____/_____ (MM/DD/AAAA)
Otro, especificar _______________________________ fecha:_____/_____/_____ (MM/DD/AAAA)
No sabe
14. El paciente desarrolló alguna complicación como resultado de la enfermedad?
Si (por favor describir/especificar)
No
No
sabe
____________________________________________________________________________________________________________________
15. El paciente tenía alguna condición médica preexistente (por ejemplo condición crónica pulmonar)
Si (por favor describir/especificar)
No
No sabe
____________________________________________________________________________________________________________________
Factores de Riesgo
16. En los 7 días previos al inicio de síntomas, liste la ubicación del paciente (incluyendo zona internacional)
Ubicación 1: Fecha: De_____/____/_____a _____/_____/____ País ____________Estado ______Ciudad/Base Patrulla Fronteriza_________
Ubicación 2: Fecha: De_____/____/____ a _____/_____/____ País ___________ Estado ______ Ciudad/Base Patrulla Fronteriza_________
Ubicación 3: Fecha: De_____/____/____ a _____/_____/____ País ____________ Estado ______ Ciudad/Base Patrulla Fronteriza_________
Ubicación 4: Fecha: De_____/____/_____a _____/_____/____ País ____________Estado ______ Ciudad/Base Patrulla Fronteriza_________
17. En qué numero de dormitorio se encontraba el paciente cuando tuvo los síntomas? ________ (dormitorio 101-110)
18. En qué numero de cama se encontraba el paciente cuando tuvo los síntomas? ___________

Appendix A: Case Investigation Form

4

UAC Respiratory Disease Cluster
Case Investigation Form
19. El paciente conoció a alguien que tuvo fiebre, síntomas respiratorio como tos o dolor de garganta u otro síntoma respiratorio como
neumonía 7 días ANTES del inicio de síntomas en el paciente?
Si (liste todos los que estuvieron enfermos antes que el paciente)
No
No sabe
Fecha de
Sexo
Nombre
Edad
inicio de
Comentarios
(M/F)
síntomas

20. Algún comentario o nota adicional?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

Appendix A: Case Investigation Form

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