Human Infection with Novel Influenza A Virus with Suspec

Human Infection with Novel Influenza A Virus
With Suspected Avian Source

Form Approved
OMB No. 0920-0004

State: ________ Date reported to health department: ___/___/_____ (MM/DD/YYYY) Date interview completed: ___/___/_____ (MM/DD/YYYY)
State Epi ID:_______________________________________________ State Lab ID: ________________________________________________
Household ID (CDC use only):_________CDC ID (CDC use only):______________________ Cluster ID (CDC use only):_____________________
1. At the time of this report, is the case
Confirmed
Probable
Case under investigation (skip to Q.3)
Not a case (skip to Q.3)
2. What is the subtype?
Influenza A(H1N1) variant
Influenza A(H1N2) variant
Influenza A(H3N2) variant
Influenza A(H5N1)
Influenza A(H7N2)
Influenza A(H7N3)
Influenza A(H7N9)
Other, please describe____________
Unknown subtype

Demographic Information
3.
4.
5.
6.
7.

Date of birth: _____/_____/_____ (MM/DD/YYYY)
Country of usual residence: ____________________________ If usual resident of U.S., county of residence: ____________________________
White
Asian
American Indian/Alaska Native
Black
Native Hawaiian/Other Pacific Islander
Race: (check
all that apply)
Hispanic or Latino
Not Hispanic or Latino
Ethnicity:
Male
Female
Sex:

Symptoms, Clinical Course, Treatment, Testing, and Outcome
8.
9.

10.
11.
12.
13.

14.
15.
16.
17.
18.
19.
20.
21.
22.
23.

What date did symptoms associated with this illness start? _____/_____/_______ (MM/DD/YYYY)
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 Other, specify
Yes
No
Unk
Does the patient still have symptoms?
Yes (skip to Q.12)
No
Unknown (skip to Q.12)
When did the patient feel back to normal? _____/_____/_____ (MM/DD/YYYY)
Did the patient receive any medical care for the illness?
Yes
No (skip to Q.29)
Unknown (skip to Q.29)
Where and on what date did the patient seek care (check all that apply)?
Doctor’s office date:_____/_____/_____ (MM/DD/YYYY)
Emergency room date:_____/_____/_____ (MM/DD/YYYY)
Urgent care clinic date:_____/_____/_____ (MM/DD/YYYY)
Health department date:_____/_____/_____ (MM/DD/YYYY)
Other _______________________________ date:_____/_____/_____ (MM/DD/YYYY)
Unknown
Was the patient hospitalized for the illness?
Yes
No (skip to Q.23)
Unknown (skip to Q.23)
Date(s) of hospital admission? First admission date:___/___/____ (MM/DD/YYYY) Second admission date:___/___/____ (MM/DD/YYYY)
Was the patient admitted to an intensive care unit (ICU)?
Yes
No (skip to Q.18)
Unknown (skip to Q.18)
Date of ICU admission: ______/_____/_______ (MM/DD/YYYY) Date of ICU discharge: ______/_____/_______ (MM/DD/YYYY)
Did the patient receive mechanical ventilation / have a breathing tube?
Yes
No (skip to Q.20)
Unknown (skip to Q.20)
For how many days did the patient receive mechanical ventilation or have a breathing tube? ___________________ days
Was the patient discharged?
Yes
No (skip to Q.23)
Unknown (skip to Q.23)
Date(s) of hospital discharge? First discharge date:___/___/____ (MM/DD/YYYY) Second discharge date:___/___/____ (MM/DD/YYYY)
Where was the patient discharged?
Home
Nursing facility/rehab
Hospice
Other _________________________
Unknown
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

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).

Human Infection with Novel Influenza A Virus
With Suspected Avian Source
24. Did the patient receive a diagnosis of pneumonia?
Yes
No
Unknown
25. Did the patient receive a diagnosis of ARDS?
Yes
No
Unknown
26. Did the patient have leukopenia (white blood cell count <5000 leukocytes/mm3) associated with this illness?
Normal
Abnormal
Test not performed
Unknown
27. Did the patient have lymphopenia (total lymphocytes <800/mm3 or lymphocytes <15% of WBC) associated with this illness?
Normal
Abnormal
Test not performed
Unknown
28. Did the patient have thrombocytopenia (total platelets <150,000/mm3) associated with this illness?
Normal
Abnormal
Test not performed
Unknown
29. Did the patient experience any other complications as a result of this illness?
Yes (please describe below)
No
Unknown
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
30. Did the patient receive influenza antiviral medications 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
Drug
(MM/DD/YYYY) (MM/DD/YYYY)
receiving antivirals
Oseltamivir (Tamiflu)
Zanamivir (Relenza)
Other influenza antiviral_____________________
31. Did the patient die as a result of this illness?
Yes, Date of death:_____/_____/_____ (MM/DD/YYYY)
No
Unknown

Dosage
(if known)
mg
mg
mg

Influenza Testing
32. When was the specimen collected that indicated novel influenza A virus infection by Reverse Transcription-Polymerase Chain Reaction (RTPCR)? ______/______/_______ (MM/DD/YYYY)
33. Where was the specimen collected?
Doctor’s office
Hospital
Emergency room
Urgent care clinic
Health department
Other ____________________________________________
Unknown
34. Was a rapid influenza diagnostic test (RIDT) used on any respiratory specimens collected?
Yes
No (skip to Q.38)
Unknown (skip to Q.38)
35. When was the RIDT specimen collected? ______/______/_______ (MM/DD/YYYY)
Influenza A
Influenza B
Influenza A/B (type not distinguished)
Negative
Other _______________
36. What was the result?
37. What brand of RIDT was used? _____________________________________________________________

Medical History -- Past Medical History and Vaccination Status
38. Does the patient have any of the following chronic medical conditions? Please specify ALL conditions that qualify.
a.

39.
40.
41.
42.
43.
44.

Asthma/reactive airway disease

Yes

No

Unknown

b.

Other chronic lung disease

Yes

No

Unknown (If YES, specify) _______________________________

c.

Chronic heart or circulatory disease

Yes

No

Unknown (If YES, specify) _______________________________

d.

Diabetes mellitus

Yes

No

Unknown (If YES, specify) _______________________________

e.

Kidney or renal disease

Yes

No

Unknown (If YES, specify) _______________________________

f.

Non-cancer immunosuppressive condition

Yes

No

Unknown (If YES, specify) _______________________________

g.

Cancer chemotherapy in past 12 months

Yes

No

Unknown (If YES, specify) _______________________________

h.

Neurologic/neurodevelopmental disorder

Yes

No

Unknown (If YES, specify) _______________________________

Yes
No
Unknown (If YES, specify) _______________________________
i. Other chronic diseases
Does the patient frequently use a stroller or wheelchair? If yes, please describe.
Yes
No
Unknown
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.45)
Unknown (skip to Q.45)
Month and year of influenza vaccination? Vaccination date 1:___/_____ (MM/YYYY) Vaccination date 2:___/_____ (MM/YYYY)
Inactivated (injection)
Live attenuated (nasal spray)
Unknown
Type of influenza vaccine (check all that apply):

2

Human Infection with Novel Influenza A Virus
With Suspected Avian Source
Epidemiologic Risk Factors
45. In the 10 days prior to illness onset, did the patient travel outside of his/her usual area? Yes No (skip to Q.49) Unknown (skip to Q.49)
46. When and where did the patient travel?
Trip 1: Dates of travel: _____/_____/_____ to _____/_____/_____ Country ______________ State _______ City/County________________
Trip 2: Dates of travel: _____/_____/_____ to _____/_____/_____ Country ______________ State _______ City/County________________
47. Did the patient travel in a group (check all that apply)?
No, travelled alone traveled
Yes, with household members
Yes, with non-household members
Unknown
48. Please describe the details of the trip ______________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Risk Factors— Livestock Animals
49. In the 10 days before becoming ill, did the patient attend an agricultural fair/event?
Yes (specify name, if >1 fair, please describe in the notes section __________________)
No (skip to Q.51)
Unknown (skip to Q.51)
50. In the 10 days before becoming ill, on what days did the patient attend an agricultural fair/event (check all that apply)?
on the day of illness onset
1 day before illness onset
2 days before illness onset
3 days before illness onset
4 days before illness onset
5 days before illness onset
6 days before illness onset
7 days before illness onset
8 days before illness onset
9 days before illness onset
10 days before illness onset
51. In the 10 days before becoming ill, did the patient visit a live animal market?
Yes, specify name __________________________________________
No (skip to Q.54)
Unknown (skip to Q.54)
52. Did the patient or their household members handle or purchase any live or freshly killed poultry from the market?
Yes
No (skip to Q.54)
Unknown (skip to Q.54)
53. In the 10 days before becoming ill, on what days did the patient visit a live animal market (check all that apply)?
on the day of illness onset
1 day before illness onset
2 days before illness onset
3 days before illness onset
4 days before illness onset
5 days before illness onset
6 days before illness onset
7 days before illness onset
8 days before illness onset
9 days before illness onset
10 days before illness onset
54. In the 10 days before becoming ill, did the patient have ANY contact with livestock animals like poultry or pigs?
Yes
No (skip to Q.75)
Unknown (skip to Q.75)
55. What type(s) of animals did the patient have ANY contact with (check all that apply)?
Horses
Cows
Poultry
Sheep
Goats
Pigs/hogs
Other____________________________
56. Where did the contact occur (check all that apply)?
Home
Commercial farm
Agricultural fair or event
Live animal market
Petting zoo
Veterinary contact
Slaughterhouse Other__________________________________
Risk Factors—Poultry

Please answer Q.57–74 if ANY contact with poultry identified above. If no contact identified, please skip to Q.75.
57. In the 10 days before becoming ill, did the patient have DIRECT (touch or handle) contact with poultry?
Yes
No (skip to Q.63)
Unknown (skip to Q.63)
58. Where did the DIRECT contact with poultry occur (check all that apply)?
Home
Commercial poultry farm
Agricultural fair or event
Live animal market
Petting zoo
Veterinary contact
Slaughterhouse Other____________________________
59. Did the patient touch or handle any poultry in the 10 days before becoming ill?
Yes
No
Unknown
60. Did the patient bathe or wash any poultry in the 10 days before becoming ill?
Yes
No
Unknown
61. Did the patient slaughter or de-feather (pluck) any poultry in the 10 days before becoming ill?
Yes
No
Unknown
62. What type(s) of poultry did the patient have DIRECT contact with (check all that apply)?
Chickens
Turkeys
Geese
Pheasants
Ducks
Ostriches
Emus
Pigeons
Other____________________________
63. In the 10 days before becoming ill, did the patient have INDIRECT (walk through an area containing or come within 6 feet of) contact with
poultry?
Yes
No (skip to Q.71)
Unknown (skip to Q.71)

3

Human Infection with Novel Influenza A Virus
With Suspected Avian Source
64. Where did the INDIRECT contact with poultry occur (check all that apply)?
Home
Commercial poultry farm
Agricultural fair or event
Live animal market
Petting zoo
Veterinary contact
Slaughterhouse Other____________________________
65. Did the patient clean any poultry pens/houses in the 10 days before becoming ill?
Yes
No
Unknown
66. Did the patient feed or water any poultry in the 10 days before becoming ill?
Yes
No
Unknown
67. Did the patient have direct contact with surfaces contaminated by poultry feces or poultry parts (carcasses, internal organs, etc.) in the 10 days
before becoming ill?
Yes
No
Unknown
68. Did the patient participate in the culling of any flocks?
Yes
No (skip to Q.70)
Unknown (skip to Q.70)
69. What measures did the patient use to protect himself/herself during the culling (check all that apply)?
None
Facemask
Respirators
Hand gloves
Eyeglasses
Gowns
Boots
Unknown
Other____________________________
70. What type(s) of poultry did the patient have INDIRECT contact with (check all that apply)?
Chickens
Turkeys
Geese
Pheasants
Ducks
Ostriches
Emus
Pigeons
Other____________________________
71. In the 10 days before becoming ill, on what days did the patient have ANY contact (direct, indirect, or both) with poultry (check all that apply)?
on the day of illness onset
1 day before illness onset
2 days before illness onset
3 days before illness onset
4 days before illness onset
5 days before illness onset
6 days before illness onset
7 days before illness onset
8 days before illness onset
9 days before illness onset
10 days before illness onset
72. From Q. 71, what was the total number of different days the patient reported ANY poultry contact (direct, indirect, or both)? ___________ days
73. Did the patient report ANY contact (direct, indirect, or both) with any ill-appearing poultry in the 10 days before becoming ill?
Yes, specify_________________________________________
No
Unknown
74. Did the patient report ANY contact (direct, indirect, or both) with dead poultry in the 10 days before becoming ill?
Yes, specify_________________________________________
No
Unknown
Risk Factors—Household poultry practices
75. Were poultry raised on the patient’s property?
Yes
No (skip to Q.83)
Unknown (skip to Q.83)
76. Where were the poultry kept (check all that apply)?
In patient’s basement or garage
Inside patient’s house/living space
Open-air poultry pen or poultry house
Enclosed poultry pen or poultry house
Other enclosure/cage outside the patient’s house
Other____________________________
77. What type(s) of poultry did the patient raise (check all that apply)? Please specify number of each type raised.
Chickens ____#
Turkeys ____#
Geese ____#
Pheasants ____#
Ducks ____#
Ostriches ____#
Emus ____#
Pigeons ____#
Other____________________________ ____#
78. Did the patient’s household have any recent ill-appearing poultry?
Yes
No
Unknown
79. Did the patient’s household have any recent poultry die-offs?
Yes
No (skip to Q.83)
Unknown (skip to Q.83)
80. Please indicate the percent of the flock that died. ________________%
81. When did the die-off begin and end? Begin date: ____/____/____ (MM/DD/YYYY)
End date: ____/____/____ (MM/DD/YYYY)
82. Was the flock culled?
Yes (date ____/____/____ MM/DD/YY)
No
Unknown
83. Did the patient have contact with any eggs from a private flock (i.e. not store bought or commercial) in the 10 days before becoming ill?
Yes
No
Unknown
84. Did the patient consume raw or undercooked poultry in the 10 days before becoming ill?
Yes
No
Unknown
85. Does anyone else in the household own, keep or care for poultry in a location other than the patient’s property?
Yes, specify_________________________________________
No
Unknown
86. Were there any recent reports of sick or dead poultry in the case patient’s area?
Yes, specify _________________________________________
No
Unknown
Risk Factors—Wild/Migratory birds
87. Did the patient visit any areas where wild/migratory birds (e.g. herons, gulls, falcons, wild ducks, geese, or swans) are present?
Yes, specify location _________________________________________
No
Unknown

4

Human Infection with Novel Influenza A Virus
With Suspected Avian Source
88. In the 10 days before illness onset, did the patient have ANY contact with wild/migratory birds?
Yes
No (skip to Q.93)
Unknown (skip to Q.93)
89. In the 10 days before illness onset, did the patient have any DIRECT contact (touch or handle) with any wild/migratory birds?
Yes, specify type of bird(s) _________________________________________
No
Unknown
90. In the 10 days before becoming ill, did the patient have INDIRECT contact (walk through an area containing or come within 6 feet of) any
wild/migratory birds?
Yes, specify type of bird(s) _________________________________________
No
Unknown
91. Were any of the wild/migratory birds that the patient had ANY contact with sick or dying?
Yes, specify___________________________________________________
No
Unknown
92. In the 10 days before becoming ill, on what days did the patient have ANY contact (direct, indirect, or both) with wild birds (check all that
apply)?
on the day of illness onset
1 day before illness onset
2 days before illness onset
3 days before illness onset
4 days before illness onset
5 days before illness onset
6 days before illness onset
7 days before illness onset
8 days before illness onset
9 days before illness onset
10 days before illness onset
Risk Factors—Other Animals
93. In the 10 days before becoming ill, did the patient have contact with an animal other than poultry or livestock (e.g. a cat or dog) that had a
confirmed influenza virus infection??
Yes
No
Unknown
Risk Factors—Household, Occupational, Nosocomial, and Secondary Spread
94. Does the patient reside in an institutional or group setting (e.g. nursing home, boarding school, college dormitory)?
Yes (skip to Q.96)
No
Unknown (skip to Q.96)
95. How many people resided in the patient’s household(s) in the week before or after illness onset (excluding the patient)? ________
A household member is anyone with at least one overnight stay +/- 7 days from patient’s illness onset, and the patient may have resided
in >1 household. Please complete the table below for each household member and continue in the notes section if more space is needed.
If HH member
If HH member
Fever or any
ILL
NOT ILL
Relation to
respiratory
Date of
patient (e.g.
Sex
Attend fair/live
Bird contact or
ID Household (HH)
Age symptom +/– 10 illness onset
Any bird contact
parent, brother, (M/F)
market ≤10 days
fair/market visit
days from case
≤10 days before
friend)
≤10 days before
before his/her
patient’s onset?
his/her onset?
patient’s onset?
onset?
1
A
B
C
Y
N
U
Y
N
U
Y
N
U
Y
N
U
2
A
B
C
Y
N
U
Y
N
U
Y
N
U
Y
N
U
3
A
B
C
Y
N
U
Y
N
U
Y
N
U
Y
N
U
4
A
B
C
Y
N
U
Y
N
U
Y
N
U
Y
N
U
5
A
B
C
Y
N
U
Y
N
U
Y
N
U
Y
N
U
6
A
B
C
Y
N
U
Y
N
U
Y
N
U
Y
N
U
96. In the 10 days before or after becoming ill, did the patient attend or work at a child care facility?
Yes (before becoming ill)
Yes (after becoming ill)
No (skip to Q.98)
Unknown (skip to Q.98)
97. Approximately how many children are in the patient’s class or room at the child care facility? ______________
98. In the 10 days before or after becoming ill, did the patient attend or work at a school?
Yes (before becoming ill)
Yes (after becoming ill)
No (skip to Q.100)
Unknown (skip to Q.100)
99. Approximately how many students are in the patient’s class at the school? ______________ children
100. In the 10 days before or after the patient became ill, did anyone else in the patient’s household(s) work at/attend a child care facility or school?
Yes
No (skip to Q.102)
Unknown (skip to Q.102)
101. List ID numbers from Q.95 (the table above) for household members working at or attending a child care facility or school:
___________f______________________________________________________________________________________________________
102. Does the patient handle samples (animal or human) suspected of containing influenza virus in a laboratory or other setting?
Yes (date ____/____/____ MM/DD/YY)
No
Unknown
103. In the 10 days before or after becoming ill, did the patient work in or volunteer at a healthcare facility or setting?
Yes
No (skip to Q.106)
Unknown (skip to Q.106)
104. Specify healthcare facility job/role:
Physician
Nurse
Administration staff
Housekeeping
Patient transport
Volunteer
Other_________________________
105. Did the patient have direct patient contact while working or volunteering at a healthcare facility?
Yes
No
Unknown

5

Human Infection with Novel Influenza A Virus
With Suspected Avian Source
106. In the 10 days before becoming ill, was the patient in a hospital for any reason (i.e., visiting, working, or for treatment)?
Yes
No
Unknown
If yes, what were the dates? ____/____/_____, ____/____/_____
City/Town ______________________________________
107. In the 10 days before becoming ill, was the patient in a clinic or a doctor’s office for any reason?
Yes
No
Unknown
If yes, what were the dates? ____/____/_____, ____/____/_____
City/Town ______________________________________
108. In the 10 days before becoming ill, did the patient have close contact (e.g. caring for, speaking with, or touching) with anyone other than their
household members who routinely has contact with birds (poultry or wild)?
Yes
No
Unknown
109. In the 10 days before becoming ill, did the patient have close contact (e.g. caring for, speaking with, or touching) with anyone who reported
travel to a country with avian influenza cases (e.g. Indonesia, Egypt, Viet Nam, China, Hong Kong, Cambodia, Thailand)?
Yes
No
Unknown
110. Does the patient know anyone other than a household member who had fever, respiratory symptoms like cough or sore throat, or another
respiratory illness like pneumonia in the 10 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
Any bird contact or fair/live market
Relationship to patient
Age
Comments
(M/F)
illness onset
visits ≤10 days before his/her onset?
Y
N
U
Y
N
U
Y
N
U
Y
N
U
111. Does the patient know anyone other than a household member who had fever, respiratory symptoms like cough or sore throat, or another
respiratory illness like pneumonia beginning AFTER the case patient’s illness onset?
Yes (please list those ill after the case patient in the table below)
No
Unknown
Sex
Date of
Any bird contact or fair/live market
Relationship to patient
Age
Comments
(M/F)
illness onset
visits ≤10 days before his/her onset?
Y
N
U
Y
N
U
Y
N
U
Y
N
U
112. Is the patient a contact of a confirmed or probable case of novel influenza A infection?
Yes (please list patient’s confirmed or probable contacts in the table below)
No
Unknown
Date of illness
Sex
Relationship to patient
State Epi ID
State Lab ID
Case status
Age
onset
(M/F)
(MM/DD/YYYY)
Confirmed
Probable
Confirmed
Probable
Confirmed
Probable
Confirmed
Probable
113. Any additional comments or notes (e.g. names/dates of fairs attended by case patient; dates of household members fair attendance and location
of fair; information about other ill contacts)?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
This is the end of the case report form. Thank you very much for your time.
Please fax completed forms to 1.888.232.1322
If you have any questions please feel free to contact the Epidemiology and Prevention Branch at 404.639.3747.

6