Harmful Algal Bloom-related Illness Surveillance System

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Form Approved
OMB No. 0920-xxxx
Expires xx/xx/xx

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Description

HAB CDC Report ID
HAB State Report ID
CDC Case ID
Report Date

CDC assigned report ID.
State assigned human case ID.
CDC assigned case ID.
The date when the report was created.

Sex
Age (years)
State of residence
Date of Exposure
Date of First Exposure
Time of First Exposure
Date of Last Exposure
Time of Last Exposure
Date of Illness Onset
Time of Illness Onset
Date of Illness Recovery
Time of Illness Recovery
Date of Death
Time of Death
Date of Notification to Authorities
Date of Interview
Time of Interview
Exposure State(s)
Exposure Count(ies)
Exposure Setting(s)
Specific Location Name(s)
Exposure Source
Exposure Activity
Exposure Activity Description
Water Type
Food Type
Activity Duration
Activity Duration Unit
Routes of Exposure
Exposure Remarks

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B

Label/Short Name

Signs or symptoms
Time to Onset
Onset Unit
Duration of Symptoms
Duration Unit
Recurrence Following Mutiple Exposures
Signs/Symptoms Consistent with Exposure
Signs/Symptoms Consistent with Food Item

C

Value Set Code

(ALPHANUMERIC)
(ALPHANUMERIC)
(ALPHANUMERIC)
(DATE)
General Information: Human Description
The sex of the human case.
(SELECT FROM LIST)
The age (in years) of the human case.
(NUMERIC)
The state of residence of the human case.
(SELECT FROM LIST)
General Information: Dates
Did the person have an exposure on a single date or multiple dates?
(SELECT FROM LIST) Single date/Multiple dates/Unknown
When was the first exposure?
(DATE)
What time did the person have their first exposure?
(TIME)
When was the last exposure?
(DATE)
What time did the person have their last exposure?
(TIME)
When did illness begin?
(DATE)
What time did the illness onset begin?
(TIME)
When did illness end?
(DATE)
What time did the illness end?
(TIME)
When did the patient die?
(DATE)
What time did the death occur?
(TIME)
When were State,Territories,Local, or Tribal Health Authorities notified?
(DATE)
When did the interview occur?
(DATE)
What time did the interview occur?
(TIME)
Human Exposure Information: Exposure Description
What state the did the exposure occur in?
(MULTISELECT)
What county the did the exposure occur in?
(MULTISELECT)
What setting the did the exposure occur in?
(MULTISELECT) e.g. State Park/Private Residence
(FREE TEXT) e.g. Cook's beach
What is the specific name of the location where the exposure occured?
(SELECT FROM LIST) e.g. Food/Water/Air/Other/Unknown
What medium was the exposure source?
What activities may have been associated with exposure?
(SELECT FROM LIST) e.g. Recreation activities/Personal use/Commerical agriculture/Farming/Non-personal
use/Aquaculture/Other/None/Unknown
Description of exposure activity.
(FREE TEXT)
Type of water body if applicable.
(SELECT FROM LIST) e.g. Lake/Beach/Community water system/Other/Unknown
(SELECT FROM LIST) e.g. Shellfish/Mussels/Finfish/Other/Unknown
Type of food if applicable.
(NUMERIC)
How long did the activity last?
(SELECT FROM LIST) Minutes/Hours/Days
What was the unit of time of the activity?
(MULTISELECT) e.g. Ingestion/Inhalation/Skin Contact/Other/Unknown
What were the routes of exposure?
(FREE TEXT)
Any additional information regarding the exposure(s)?
Illness and Health Outcomes: Signs and Symptoms of Illness
(SELECT FROM LIST) e.g Lethargy/Ear Discharge/Rash/Other/Unknown
What signs or symptoms of illness were experienced?
(NUMERIC)
What was the time to illness onset?
(SELECT FROM LIST) Minutes/Hours/Days
What was the unit of time?
(NUMERIC)
How long did the symptom(s) last?
(SELECT FROM LIST) Minutes/Hours/Days
What is the unit of time?
Did the symptom reoccur after secondary, tertiary, etc exposures?
Yes No Unknown (YNU)
Was the sign/symptom consistent with the route of exposure?
Yes No Unknown (YNU)
If food was implicated, were the signs/symptoms consistent with foodborne
Yes No Unknown (YNU)
fish/shellfish poisoning?

Form Approved
OMB No. 0920-xxxx
Expires xx/xx/xx

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Poisoning Description
Signs/Symptoms Remarks

Care from Non-medical Provider
Healthcare Visit
Emergency Department Visit
Poison Control Contact
Death
Additional Medical/Health Outcome
56
Information
57 Medical Care and Health Outcome Remarks
58
59 Chronic Respiratory Disease
60 Tobacco Use
61 Chronic Skin Disease
62
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Allergies
Chronic Gastrointestinal Disease
Chronic Kidney Disease

65 Liver Disease
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67

Chronic Neurologic Diseased
Immunocompromised

68 Alcohol Consumption within 24 Hours
69 Pregnant
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Skin Sensitivity due to Medication
OTC Pain Medication
Open Wounds
Communicable Diseases
Environmental Irritants

75 Other Causes Investigated
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Other Environmental Sample Testing

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78 Clinical Specimen Testing
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Type of Clinical Testing
Classification
Genus or Toxin
Species
Subspecies/Serotype/Genotype
Specimen Detection
Concentration

B

C

Characterization of foodborne poisoning symptoms.
(SELECT FROM LIST) e.g. PSP/Ciguatera/Other
Additional comments for signs/symptoms.
(FREE TEXT)
Illness and Health Outcomes: Medical Care and Health Outcomes
Did the person receive first aid care from a non-medical provider?
Yes No Unknown (YNU)
Did the person visit a healthcare provider?
Yes No Unknown (YNU)
Did the person go to an emergency department?
Yes No Unknown (YNU)
Was a poison control center contacted?
Yes No Unknown (YNU)
Did the person die?
Yes No Unknown (YNU)
Do you have additional information about medical care or health outcomes for this Yes No Indicator (HL7)
person?
Additional comments for medical care and health outcomes.
(FREE TEXT)
Illness and Health Outcomes: Health History and Differential Diagnosis
Does the person have a history of chronic respiratory disease e.g. asthma, COPD?
Yes No Unknown (YNU)
Does the person have a history of tobacco use?
Yes No Unknown (YNU)
Yes No Unknown (YNU)
Does the person have a history of skin disease e.g. psoriasis, eczema?
Does this person have a history of allergies to food, medication, or other substances? Yes No Unknown (YNU)
Does this person have a history of chronic gastrointestinal disease e.g. Crohn's
Yes No Unknown (YNU)
disease?
Does this person have a history of chronic kidney disease e.g. caused by hypertension, Yes No Unknown (YNU)
diabetes, extended use of NSAIDs?
Yes No Unknown (YNU)
Does this person have a history of liver disease e.g. hepatitis or cirrhosis?
Does this person have a history of chronic neurologic disease e.g. caused by diabetes? Yes No Unknown (YNU)
Was the person immunocompromised due to medication or illness e.g. transplant
Yes No Unknown (YNU)
recipient, diabetic?
Did the person drink any alcohol within 24 hours prior to symptoms?
Yes No Unknown (YNU)
Was the person pregnant?
Was the person taking medications that increased skin sensitivity to the sun e.g. acne Yes No Unknown (YNU)
treatment, antibiotics?
Did the person frequently take over the counter (OTC) pain medication e.g. more than Yes No Unknown (YNU)
5 times a week?
Did the person have an open wound, sores, or broken skin at th etime of exposure? Yes No Unknown (YNU)
Had the person recently been exposed to any communicable diseases that cause
similar signs or symptoms?
Had the person recently been exposed to any environmental irritants that cause
similar signs or symptoms e.g. poison ivy/oak?
Were other causes of the illness investigated?
Were environmental samples tested to rule out other possible causes e.g.
mushrooms?
Clinical Testing
Were clinical specimens tested?
What type of clinical testing was performed to diagnose the illness or rule out other
causes?
What broad category of pathogen/toxin does the test result fall within?
What is the genus or toxin name?
What is the species name?
What is the subspecies, serotype, or genotype?
What type of clinical specimen tested positive?
What was the concentration of the test result?

Yes No Unknown (YNU)
Yes No Unknown (YNU)
Yes No Unknown (YNU)
Yes No Unknown (YNU)

Yes No Unknown (YNU)
(MULTISELECT) e.g. Bloodwork/Culture/Fecal analysis/Histopathology/Skin biopsy/Stomach content
analysis/Toxicology/Urinalysis/X-ray/Other/Unknown
(SELECT FROM LIST)
(SELECT FROM LIST)
(SELECT FROM LIST)
(SELECT FROM LIST)
(SELECT FROM LIST) e.g. Blood/Stool/Tissue/Stomach Contents/Other
(NUMERIC)

Form Approved
OMB No. 0920-xxxx
Expires xx/xx/xx

A
86 Concentration Unit
87 Test Type
88 Clinical Testing Remarks
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90 General Remarks
91 Attachments
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93 Report Author
94 Reporting Site Name
95 Agency Name
96 Agency Contact Name
97 Agency Contact Title
98 Agency Contact Phone
99 Agency Contact Fax
100 Agency Contact Email

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What is the test result unit of concentration?
What was the type of test that was performed?
Additional remarks regarding clinical testing?
Additional remarks regarding the human case.
Additional attachments regarding the human case.
Who is the author of the report?
What is the name of the reporting site?
What is the name of the agency?
Who is the agency contact?
What is the agency contact's title?
What is the agency contact's phone number?
What is the agency contact's fax number?
What is the agency contact's email address?

C

(SELECT FROM LIST)
(SELECT FROM LIST)
(FREE TEXT)
Supplemental Information
(FREE TEXT)
(UPLOAD) e.g. word document,excel spreadsheet, image
Report Administration
(FREE TEXT)
(FREE TEXT)
(FREE TEXT)
(FREE TEXT)
(FREE TEXT)
(FREE TEXT)
(FREE TEXT)
(FREE TEXT)

Form Approved
OMB No. 0920-xxxx
Expires xx/xx/xx

Label/Short Name

Description

HAB CDC Report ID
HAB State Report ID
CDC Case ID
Report Date

CDC assigned report ID.
State assigned animal case ID.
CDC assigned case ID.
The date when the report was created.

Animal Category
Animal Type
Animal Desciption
Single/Group of Animal(s)
Single Animal Age
Single Animal Weight
Single Animal Death
Single Animal Condition
Group Animals Affected
Group Animal Deaths
Group Animal Death Count
Group Animal Condition
Date of Exposure
Date of First Exposure
Time of First Exposure
Date of Last Exposure
Time of Last Exposure
Date of Discovery
Time of Discovery
Date of Illness Onset
Time of Illness Onset
Date of Death
Time of Death
Date of Notification to Authorities
Date Remarks
Exposure State(s)
Exposure Count(ies)
Exposure Setting(s)
Specific location name(s)
Exposure Activity
Exposure Activity Description
Water Type
Food Type
Activity Duration
Routes of Exposure
Exposure Remarks
Signs
Time to Onset
Onset Unit
Duration of Signs
Duration Unit
Recurrence Following Mutiple Exposures
Signs Consistent with Exposure
Veterinary Treatment

Value Set Code

(ALPHANUMERIC)
(ALPHANUMERIC)
(ALPHANUMERIC)
(DATE)
General Information: Animal Description
(SELECT FROM LIST) e.g. Domestic pet/Livestock/Wildlife/Other/Unknown
What is the category of animal(s) being reported?
What type of animal(s) are you reporting?
(SELECT FROM LIST) Animal Type (FDD)
(FREE TEXT) e.g. dog breed, cat breed, type of bird, amphibian, reptile, other, or other mammal
Additional animal(s) description.
Does this illness report describe a single animal or a groupof animals e.g. school (SELECT ONE) Single Animal/Group of Animals
of fish, flocks, herds?
What is the age of the animal?
(NUMERIC)
What is the weight of the animal (kg/lb)?
(NUMERIC)
Did the animal die?
Yes No Unknown (YNU)
What condition was the animal found in?
(MULTISELECT) e.g. Alive/Fresh/Scavenged/Decomposed/Unknown/Not applicable
How many animals were affected?
(NUMERIC)
Did any animals die?
Yes No Unknown (YNU)
How many dead animals were counted?
(NUMERIC)
What condition were the animals found in?
(MULTISELECT) e.g. Alive/Fresh/Scavenged/Decomposed/Unknown/Not applicable
General Information: Dates
Did the person have an exposure on a single date or multiple dates?
(SELECT FROM LIST) Single date/Multiple dates/Unknown
When was the first exposure?
(DATE)
What time did the first exposure occur?
(TIME) AM/PM
When was the last exposure?
(DATE)
What time did the last exposure occur?
(TIME) AM/PM
When was the animal discovered?
(DATE)
What time was the animal discovered?
(TIME) AM/PM
When did the illness begin?
(DATE)
What time did the illness begin?
(TIME) AM/PM
When did the animal(s) die?
(DATE)
What time did the animal(s) die?
(TIME) AM/PM
When were State,Territories,Local, or Tribal Health Authorities notified?
(DATE)
Additional remarks regarding the date.
(FREE TEXT)
Animal Exposure Information: Exposure Description
What state did the exposure occur in?
(MULTISELECT)
What county did the exposure occur in?
(MULTISELECT)
(MULTISELECT) e.g. State Park/National Park/Private Residence
What setting did the exposure occur in?
(FREE TEXT) e.g. Cook's beach
What is the specific name of the location where the exposure occurred?
What activities may have been associated with exposure?
(SELECT FROM LIST) e.g. Recreation activites/Swimming/Other/None/Unknown
Description of exposure activity.
(FREE TEXT)
Type of water body if applicable.
(SELECT FROM LIST) e.g. Lake/Beach/Community water system/Other/Unknown
(SELECT FROM LIST) e.g. Shellfish/Mussels/Finfish/Other/Unknown
Type of food if applicable.
(Minutes/Hours/Days)
How long did the activity last?
(MULTISELECT) e.g. Ingestion/Inhalation/Skin Contact/Other/Unknown
What were the routes of exposure?
(FREE TEXT)
Any additional information regarding the exposure(s)?
Signs of Illness and Health Outcomes: Signs of Illness
(SELECT FROM LIST) e.g. Lethargy/Ear Discharge/Rash/Other/Unknown
What signs of illness were observed?
(NUMERIC)
What was the time to illness onset?
(SELECT FROM LIST) Minutes/Hours/Days
What was the unit of time?
(NUMERIC)
How long did the sign(s) last?
(SELECT FROM LIST) Minutes/Hours/Days
What is the unit of time?
Did the sign reoccur after secondary, tertiary, etc exposures?
Yes No Unknown (YNU)
Was the sign consistent with the route of exposure?
Yes No Unknown (YNU)
Signs of Illness and Health Outcomes: Medical Care and Health Outcomes
Did the animal(s) receive veterinary medical care or treatment?
Yes No Unknown (YNU)

Form Approved
OMB No. 0920-xxxx
Expires xx/xx/xx

Veterinary Admission
Additional Medical/Health Outcome Information

Did the animal(s) get admitted to a veterinary facility?
Yes No Unknown (YNU)
Do you have additional information about medical care or health outcomes for Yes No Indicator (HL7)
the animal(s)?
Medical Care and Health Outcome Remarks
(FREE TEXT)
Additional information regarding the animal(s) medical care and health
outcome.
Signs of Illness and Health Outcomes: Health History and Differential Diagnosis
Did the animal(s) have any pre-existing conditions or disabilities?
Pre-existing Conditions
Yes No Unknown (YNU)
Did the animal(s) receive any medications in the month before illness onset?
Medications
Yes No Unknown (YNU)
Were other causes of illness investigated?
Other Causes Investigated
Yes No Unknown (YNU)
Other Environmental Sample Testing
Were environmental samples tested to rule out other possible causes e.g.
Yes No Unknown (YNU)
mushrooms?
Health History and Differential Diagnosis Remarks Additional remarks regarding the animal(s) health history and differential
(FREE TEXT)
diagnosis.
Clinical Testing
Clinical Specimen Testing
Were clinical specimens tested?
Yes No Unknown (YNU)
Type of Clinical Testing
What type of clinical testing was performed to diagnose the illness or rule out
(MULTISELECT) e.g. Bloodwork/Culture/Fecal analysis/Histopathology/Skin biopsy/Stomach content
other causes?
analysis/Toxicology/Urinalysis/X-ray/Other/Unknown
Classification
What broad category of pathogen/toxin does the test result fall within?
(SELECT FROM LIST)
(SELECT FROM LIST)
Genus or Toxin
What is the genus or toxin name?
(SELECT FROM LIST)
Species
What is the species name?
(SELECT FROM LIST)
Subspecies/Serotype/Genotype
What is the subspecies, serotype, or genotype?
(SELECT FROM LIST) e.g. Blood/Stool/Tissue/Stomach Contents/Other
Specimen Detection
What type of clinical specimen tested positive?
(NUMERIC)
Concentration
What was the concentration of the test result?
(SELECT FROM LIST)
Concentration Unit
What is the test result unit of concentration?
(SELECT FROM LIST)
Test Type
What was the type of test that was performed?
(FREE TEXT)
Clinical Testing Remarks
Additional remarks regarding clinical testing?
Supplemental Information
(FREE TEXT)
General Remarks
Additional remarks regarding the animal case.
(UPLOAD) e.g. word document,excel spreadsheet, image
Attachments
Additional attachments regarding the animal case.
Report Administration
(FREE TEXT)
Report Author
Who is the author of the report?
(FREE TEXT)
Reporting Site Name
What is the name of the reporting site?
(FREE TEXT)
Agency Name
What is the name of the agency?
(FREE TEXT)
Agency Contact Name
Who is the agency contact?
(FREE TEXT)
Agency Contact Title
What is the agency contact's title?
(FREE TEXT)
Agency Contact Phone
What is the agency contact's phone number?
(FREE TEXT)
Agency Contact Fax
What is the agency contact's fax number?
(FREE TEXT)
Agency Contact Email
What is the agency contact's email address?

Label/Short Name

Description

Value Set Code

HAB CDC Report ID
HAB State Report ID
CDC Case ID
Report Date

CDC assigned report ID.
State assigned animal case ID.
CDC assigned case ID.
The date when the report was created.

(ALPHANUMERIC)
(ALPHANUMERIC)
(ALPHANUMERIC)
(DATE)

Date of First Bloom
Other Event
Date of Notification to Authorities
Date Remarks
State/Jurisdiction
Count(ies)
Other States Affected
Other States
Official Name of Water Body
Common Name of Water Body
Specific Location Name(s)
Nearest City/Town
Latititude
Longitude
Hydrologic Unit Code
Water Type
Water Salinity
Water Body of Bloom
Geographic Description Remarks
Type of Advisory/Warning
Advisory/Warning Response
Advisory/Warning Agency
Advisory Criteria/Reason
Advisory/Warning Start Date
Advisory/Warning End Date
Date Documented
Documented By
Scum/Algal Matter Observed
Water Color
Water Clarity
Water Odors
Water Flow
Tidal Conditions
Samples Tested
Reason Samples Tested
Water Testing
Classification
Genus or Toxin
Species
Subspecies
Sample Detection
Sample Description
Concentration
Concentration Unit
Test Type
Sample Collection Date
Sample Collection Time
Laboratory Testing Remarks

Form Approved
OMB No. 0920-xxxx
Expires xx/xx/xx

General Information: Dates
When was the bloom first observed?
(DATE)
(SELECT FROM LIST) e.g. Foodborne intoxication/Other evidence of Harmful algal toxicity
Reason for report, if no date of first bloom.
When were State,Territories,Local, or Tribal Health Authorities notified?
(DATE)
Additional information regarding dates.
(FREE TEXT)
General Information: Geographic Description
What state(s)/jurisdiction(s) did the event occur in?
(SELECT FROM LIST)
What count(ies) did the event occur in?
(MULTISELECT)
Did an algal bloom impact water quality in any other states?
Yes No Unknown Not applicable
What other states were affected?
(SELECT FROM LIST)
What is the official name of the water body?
(FREE TEXT)
What is the common name of the water body?
(FREE TEXT)
(FREE TEXT) e.g. Cook's beach
What is the specific name of the location?
What is the nearest City/Town?
(FREE TEXT)
What is the latitude of the event?
(NUMERIC)
What is the longitude of the event?
(NUMERIC)
What is the hydrologic unit code?
(MULTISELECT)
What water type did the event occur in? What was the type of water body?
(SELECT FROM LIST)
(SELECT FROM LIST) e.g. Fresh/Brackish/Salt
What sality was the water body?
What is the water body, or if applicable, the area of the water body where the
(MULTISELECT) e.g. Agriculture/Aquaculture/Industrial-Occupational/Public drinking water system/Raw
bloom was located, used for?
water, non-potable/Recreation/Other/None/Unknown
Additional information regarding geographic description.
(FREE TEXT)
Bloom Description: Health Advisories/Warnings
(SELECT FROM LIST) e.g. Health advisory/No contact warning/Water body closure (recreational
If an advisory/warning was issued, what was type of advisory/warning?
activity)/Water body closure (fish/shellfish)/Other
Yes No Unknown Not applicable
Was there a response issued for the type of advisory/warning?
What agency if applicable issued the advisory/warning?
(FREE TEXT)
What criteria/reason was the advisory issued for?
(FREE TEXT)
What date did the advisory/warning begin?
(DATE)
What date did the advisory/warning end?
(DATE)
Bloom Description: Observational Data
What day did the event occur?
(DATE)
(SELECT FROM LIST) e.g. General public, State, Local, other
Who documented the event?
Was any scum or algal matter observed?
Yes No Unknown (YNU)
(SELECT FROM LIST) e.g. Red/Yellow/Green
What color was the water?
(SELECT FROM LIST) e.g. Clear/Muddy
What was the water clarity?
Did the water have an odor?
Yes No Unknown (YNU)
Was there water flow?
(SELECT FROM LIST) Moving/Stagnant/Unknown
Were there tidal conditions?
(SELECT FROM LIST) High tide/Low Tide/Not applicable
Laboratory Testing: Algae, Algal Toxins or Components Testing
(MULTISELECT) e.g. Air/Algae/Finished drinking water/Food/Raw water, ambient/No testing/Other/Unknown
What was tested for algae, algal toxins or components?
(MULTISELECT) e.g. Fish illness,kill/Animal health event response/Citizen complaint/Human health event
If testing was conducted, why was it tested?
response/Monitoring/Odor/Other/Unknown
If water testing was performed, were any of the following tests conducted?
(MULTISELECT) e.g. Algae/Algal toxins/Chlorophyll/Copper sulfate/Enterococci/Fecal coliforms/Other
Laboratory Testing: Laboratory Results
What broad category of pathogen/toxin does the test result fall within?
(SELECT FROM LIST)
(SELECT FROM LIST)
What is the genus or toxin name?
(SELECT FROM LIST)
What is the species name?
(SELECT FROM LIST)
What is the subspecies?
(SELECT FROM LIST) e.g. Blood/Stool/Tissue/Stomach Contents/Other
What type of environmental sample tested positive?
(FREE TEXT)
Description of the environmental sample that tested postitive.
(NUMERIC)
What was the concentration of the test result?
(SELECT FROM LIST)
What was the test result unit of concentration?
(SELECT FROM LIST)
What was the type of test that was performed?
(DATE)
What date were the samples collected?
What time were the samples collected?
(TIME)
(FREE TEXT)
Additional remarks regarding laboratory testing?

System Type
System Name
System Report ID Number
Brief Description of Linked Information
General Remarks
Attachments
Report Author
Reporting Site Name
Agency Name
Agency Contact Name
Agency Contact Title
Agency Contact Phone
Agency Contact Fax
Agency Contact Email

Links to Other Systems: Links to Other Data Systems Containing Information About the Bloom
(SELECT FROM LIST) Federal/State
What the type of system?
(SELECT FROM LIST) e.g. NPS HAB surveillance/NORS
What is the system name?
(FREE TEXT)
What is the system report ID number?
(FREE TEXT)
Descripton of linked information.
Supplemental Information
(FREE TEXT)
Additional remarks regarding the environmental event.
(UPLOAD) e.g. word document,excel spreadsheet, image
Additional attachments regarding the environmental event.
Report Administration
(FREE TEXT)
Who is the author of the report?
(FREE TEXT)
What is the name of the reporting site?
(FREE TEXT)
What is the name of the agency?
(FREE TEXT)
Who is the agency contact?
(FREE TEXT)
What is the agency contact's title?
(FREE TEXT)
What is the agency contact's phone number?
(FREE TEXT)
What is the agency contact's fax number?
(FREE TEXT)
What is the agency contact's email address?

Form Approved
OMB No. 0920-xxxx
Expires xx/xx/xx