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pdfForm Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Questionnaire for Passengers and Crew
MERS-CoV Aircraft Contact Investigation
Public reporting burden of this collection of information is estimated to average 20 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-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
DGMQ ID_Number______________
Questionnaire for Passengers and Crew, MERS-CoV Aircraft Contact Investigation
Identifying and Residency Information
1. Traveler’s name: _________________________________________________
2. Type of Traveler (circle):
passenger
crew
3. Home Phone: _________________________ 4. Mobile Phone: ____________________
(circle best number to reach at)
5. E-mail address: _________________________________
6. Home address (or address for next 14 days if nonresident): ____________________
______________________________________________________________________
7. State______________
8. Zip ____________
9. If non-US resident, country of residence: _________________________________
Attempt(s) to reach traveler:
Date
Time
Outcome
Message left/e-mail sent
Interview completed / not completed
Interview completed / not completed
Interview completed / not completed
Interview completed / not completed
Interview completed / not completed
Name of person answering the questions (if not traveler): ____________________________
Relationship of person answering questions to traveler: ____________________________
Name of Interviewer: ___________________________
Agency/Affiliation of Interviewer:______________________________________
Verbal consent/parental permission obtained? Circle: Yes / No
For serology? Yes / No
For minors (13-17): Assent obtained? Circle: Yes / No If NO, parent interviewed on
child’s behalf? Circle: Yes / No
Interview date (mm/dd/yy) ___/___/14
Assent for serology? Yes / No
Telephone
In-person
E-mail
Other _______
1
DGMQ ID_Number______________
A. Demographic Information
10. Age: ______ years / months (circle one)
11. Sex (circle one):
M
F
B. Flight History for Passenger (for crew member, skip to Section C)
The airline(s) has/have indicated that you were a passenger on the following flight(s). The next
set of questions pertain to that/those specific flight(s).
Questions 12-14 should be repeated for each flight, as applicable
NOTE: If passenger was not on any of the above flights, the interview is completed.
Questions for Flight(s)
12a. Confirm passenger traveled on [check flight(s) below]
o
o
o
o
Flight Leg A, May 1st, 2014
Flight Leg B, May 1st, 2014
Flight Leg C, May 1st, 2014
Flight Leg D, May 1st, 2014
Yes
Yes
Yes
Yes
No
No
No
No
Unsure
Unsure
Unsure
Unsure
If NO or unsure, provide code share info. Check other flights. If not on any of the flights,
then the interview is complete.
If YES,
13a: Did you sit in your assigned seat for this entire flight ?
Yes – Skip to Question 14a
No
Don’t remember
13a.1. If no, how long did you sit in your assigned seat?
<30 minutes
30-60 minutes
> 60 minutes
Don’t remember
13a.2. What other seat number did you sit in for all or part of the flight?
Seat Number: _______
Don’t remember
13a.3. If passenger doesn’t remember which seat number, ask to describe which part of
the plane she or he sat in. ________________________________________________
13a.4. How long did you sit in this other seat?
<30 minutes
30-60 minutes
> 60 minutes
Don’t remember
2
DGMQ ID_Number______________
14a. Were you traveling with anyone else on this flight?
Yes –complete table below
No – Skip to Question 14b
14.a.1. Who did you travel with? [This information will help make sure we can contact
her or him about possible exposure during the flight.]
Name (last, first)
Relation*
Phone
_______________________
_______________
______________
_______________________
_______________
______________
_______________________
________________
______________
*A. friend
B. colleague C. household member** D. non-household family member
** If household member(s), ask to interview that person when done with this interview
14b. Did you come into contact with anyone who seemed ill with respiratory symptoms (such
as cough or difficulty breathing) or appeared feverish?
Yes
No
14c. Did you assist them in any way? If yes, please explain.
_______________________________________________________________________
C. Flight History for Crew Member (For passenger, skip to Section D)
15. Confirm that crew member worked on
o
o
o
o
Flight Leg A, May 1st, 2014
Flight Leg B, May 1st, 2014
Flight Leg C, May 1st, 2014
Flight Leg D, May 1st, 2014
Yes
Yes
Yes
Yes
No
No
No
No
Unsure
Unsure
Unsure
Unsure
IF NO, interview is complete. Thank the person for her/his time.
If YES, continue
16. Crew type (circle all that apply) or Cabin for passenger
Flight Deck: Captain
First Officer
Flight engineer/ navigator
Other (such as jumpseater; specify): ________________________
Cabin:
First Class
Business Class
3
DGMQ ID_Number______________
Economy Class(specify section if assigned to a specific one): __________
Lead Flight Attendant
17. Did you come into contact with anyone who seemed ill with respiratory symptoms (such as
cough or difficulty breathing) or appeared feverish?
Yes
No
18. Did you assist them in any way? If yes, please explain.
_______________________________________________________________________
D. Illness and Medical History
19. Have you been ill since the day of the flight?
Yes
No
IF YES, GO TO 20. IF NO, GO TO APPENDIX I (SEROLOGY). THEN…
Read end script for asymptomatic contact.
Send Information Notice to traveler by e-mail or fax.
20. Have you had any of the following symptoms since your flight?
a. Fever (measured temp of > 100.40 F (380 C)
Yes (Temp if known _____°)
b. Coughing
Yes
No
No
Don’t Know
c. Difficulty breathing or shortness of breath
d. Wheezing
Yes
No
e. Pain with coughing or breathing
f. Other symptom(s):
Don’t Know
Yes
No
Don’t Know
Don’t Know
Yes
No
Don’t Know
Yes; List: ____________________
No
Don’t Know
IF NO/DON’T KNOW TO 20 a-e, GO TO APPENDIX I (SEROLOGY). THEN…
Read end script for asymptomatic contact.
Send Informational Notice for MERS-CoV Exposure on Airplane to traveler
by e-mail or fax.
21. What date did you first become ill with these symptoms? (Date : ____/____/14)
If sick on or before date of flight, complete interview, then consult medical officer
before giving advice to patient.
22. Are you still sick?
Yes
No
22a. If NO, when did you feel better? Date__/__/14
4
DGMQ ID_Number______________
23. Did you see a doctor for this illness?
Yes
No
If YES,
a. What date were you seen? Date__/__/14
b. Did you receive any treatment for the illness?
Yes
No
i. If YES, specify: _____________________________________
c. Were you tested by a medical provider for the illness (including, but not
limited to, providing a blood sample, or nasal or throat swab) since the day of
your flight?
Yes
No
i. If YES – Specify test or what kind of specimen was tested for you (e.g.,
blood, nasal swab, throat swab.): _______
1. Date (mm/dd/yy) ____/____/14
2. Facility where tested_____________________
d. Were you admitted to the hospital (kept overnight, not just in emergency
room)? YES/NO
If yes, which hospital? ________________
24. Do you have any medical conditions that you are treated for regularly?
Yes (Specify: ______________)
No
Don’t Know
25. For women: Are you currently pregnant?
Yes
No
Don’t Know
E. GEOGRAPHIC EXPOSURES
26. Have you visited the Middle East since April 17th?
Yes
No If NO, skip to Question 28.
a. If YES : Dates of visit (mm/dd/yy) ____/____/14 to ____/____/14
b. List country(ies): ___________________________
c. (Omit for crew) What was the purpose of your trip? (check all that apply)
Visit family/friends
Personal travel
Business
Study
Other, specify_______
27. While you were in the Middle East, did you:
a. Have any close contact with someone who was sick with MERS-Coronavirus?
Yes
No
b. Have any close contact with someone who was sick with a serious respiratory
infection, such as pneumonia? Yes
No
5
DGMQ ID_Number______________
c. Visit a health care facility?
Yes
No
d. (Omit for crew) Work in a health care facility?
e. Have any animal exposures?
Yes
Yes
No
No
If yes: name animals
1: ______________ (describe) ___________________, date:____/____/____
2: ______________ (describe) ___________________, date:____/____/___
3: ______________ (describe) ___________________, date:____/____/____
F. Household Contacts
28. Has anyone in your household or someone else you have had close contact with had
fever, cough, difficulty breathing, or other symptoms similar to what you described?
Yes ***
No
Don’t Know (*** Note this person’s name and contact information on the
form for follow-up by local health department.)
1. Name(s): ____________________________________
Relationship: __________________________________
Symptoms: _________________________________________
Date of onset (mm/dd/yy) ____/____/____
Address: ____________________________________________
Phone #: ________________________
2. Name: ____________________________________
Relationship: __________________________________
Symptoms: _________________________________________
Date of onset (mm/dd/yy) ____/____/____
Address: ____________________________________________
Phone #: ________________________
6
Form Approved
OMB No. 0920‐1011
Exp. Date 03/31/2017
Serology Consent/Assent Script for Asymptomatic Passengers and Crew
As part of our contact investigation we are asking passengers and crew to get a blood test for MERS.
The test will help tell us if some people exposed to MERS can be infected without showing symptoms.
This would involve drawing a small amount of blood (for adults 1 teaspoon, for infants or young children
half a teaspoon or less). There will be no cost to you for doing this testing. Drawing blood can cause
some pain, bruising or a small amount of bleeding at the site of the blood draw, and can make some
people feel lightheaded.
We will give you the results of the test, but they will not be available in time to make any decisions
about your health care. Leftover blood will be stored at CDC and might be used for MERS testing in the
future, such as developing new tests for MERS infection. If you agree to do the blood test, we will follow
up with you at a later date (in approximately 2‐3 weeks) with more details about how and where to have
your blood drawn.
Do you have any questions?
Would you be willing to let us do a MERS blood test? Yes
No
If NO: thank the person for their time.
Public reporting burden of this collection of information is estimated to average 5 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‐74 Atlanta, Georgia 30333; ATTN:
PRA (0920‐1011)
Case ID# ____________
Form Approved
OMB No. 0920‐1011
Exp. Date 03/31/2017
Chart Abstraction Form – Legionnaires’ Disease
SECTION I. SCREENING FOR SUSPECT LD CASES
MRN:________________________________________________________________
Encounter (FIN): _______________________________________________________
Gender: _______
DOB: _______________ Age: _____ Race/Ethnicity: _____________________
Type of Residence: □ Home □ LTCF □ Other ___________
Todays date: __ / __ / __
Date of admission: __ / __ / __
Abstractors initials: ________
Did any of the following develop >48 hours of admission (do not count if present on
admission)?
1. Pneumonia symptoms? (Cough, shortness of breath)
□ Yes □ No (if yes, then con nue to Sec on II)
2. Abnormal CXR / CT suggestive of pneumonia/infiltrate?
□ Yes □ No (if yes, then con nue to sec on II)
3. Was another etiology identified (other than Legionella)?
□ Yes □ No (if yes, then stop)
Page 1 of 8
Public reporting burden of this collection of information is estimated to average 90 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-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
Case ID# ____________
SECTION II. TYPE OF CASE
Information Source (check all that apply):
□ hospital chart
□ other (if other specify) ______________
1. Type of exposures to Hospital A during incubation period (check all that apply):
□ Inpa ent □ Outpa ent □ Visitor □Volunteer □Employee
2. Case definition:
□ Confirmed Case □ Suspected Case □ Possible Case □ Subclinical case
3. Case Classification:
□ Definitely outbreak‐associated □ Possibly outbreak‐associated
□ Non‐outbreak associated
If non‐outbreak‐associated, END HERE. Otherwise, continue to next page.
SECTION III. LEGIONELLA‐SPECIFIC TESTING
1. Respiratory specimen collected and processed specifically for Legionella culture?
_____ Yes ______ No _____ Unknown
a.) If YES,
Specimen type: (e.g., expectorated sputum, BAL, etc.) __________________
Collected Date: ____/____/ ____ Laboratory Name:____________________
Results:________________________________________________________
b.) If NO,
Respiratory specimen collected for any culture?
_____ Yes ______ No _____ Unknown
If Yes,
Specimen type: (e.g., expectorated sputum, BAL, etc.) ____________________
Collected Date: ____/____/ ____ Laboratory: ___________________________
Results:__________________________________________________________
2. Urine specimen collected for Legionella urine antigen testing?
_____ Yes
______ No
_____ Unknown
Collected Date: ____/____/ ____ Laboratory Name: ________________________
Results: ____________________________________________________________
3. Other Legionella testing? ________________________________________________
SECTION IV. MEDICAL HISTORY
Page 2 of 8
Case ID# ____________
□ COPD/Emphysema/Chronic Lung Disease
□ Diabetes
□ Conges ve Heart Failure
□ History of stroke/CVA
□ Chronic Renal Insuffiency (CRI/CKD) or End‐Stage Renal Disease (ESRD)
□ Cirrhosis / Liver Disease
□ Cancer (Type: ________________; Date of diagnosis __/__/__)
□ Organ Transplant (Type:__________________) Date of transplant: __ / __ / __
□ Bone Marrow Transplant; Date of transplant: __ / __ / __
□ HIV/AIDS, CD4 count: ____________ Date: __ / __ / __
□ Dementia
□ Taking systemic steroid
□ History of chemotherapy Date: __ / __ / __ (Is this 1st cycle of induction chemo? □ Yes □ No)
□ History of radiation Date: __ / __ / __
□ History of pneumonia in prior year, Date: __ / __ / __
□ Other (___________________________)
□ Other (___________________________)
History of smoking: □ Yes □ No □ Unknown
If yes: □ Current □ Former □ Unknown
History of alcohol abuse: □ Yes □ No □ Unknown
History of other substance abuse: □ Yes □ No □ Unknown
Specify substance(s): _________________________________
Page 3 of 8
Case ID# ____________
SECTION V. SIGNS AND SYMPTOMS
□ Shortness of breath; Date of onset: __ / __ / __
□ Cough; Date of onset: __ / __ / __
□ Fever >100.5°F; Date of onset: __ / __ / __
□ Diarrhea (3 stools/24h); Date of onset: __ / __ / __
□ Nausea or Vomiting; Date of onset: __ / __ / __
□ Confusion (altered mental status); Date of onset: __ / __ / __
□ Other (____________);Date of onset: __ / __ / __
□ Other (____________);Date of onset: __ / __ / __
BEST SYMPTOM ONSET DATE: __ / __ / __
(If the patient did not have prior respiratory symptoms, choose, the onset date of cough or
shortness of breath, whichever occurs first. Otherwise, use the earliest date when other
symptoms suggestive of Legionella infection began.)
SECTION VI. RADIOGRAPHIC FINDINGS
Document any radiographic findings 14 days after onset of symptoms above. If multiple chest
images are available, report the first for which evidence of pneumonia is noted.
□ Chest X‐ray
If Yes, when and what were the findings?
Date: ____/____ / _____
□ Normal
□ Abnormal
Result:
□ New Infiltrate □ Old / Unchanged Infiltrate □ Indeterminate □ Consolida on
□ No infiltrate □ Not available / Unknown
Findings (impression): _____________________________________________________
□ CT Scan
If Yes, when and what were the findings?
Date: ____/____ / _____
□ Normal
□ Abnormal
Result:
□ New Infiltrate □ Old / Unchanged Infiltrate □ Indeterminate □ Consolida on
□ No infiltrate □ Not available / Unknown
Findings (impression): _____________________________________________________
Page 4 of 8
Case ID# ____________
SECTION VII. VITAL SIGNS
Highest O2 demand (FiO2): _______________________ Date (earliest):__________________
Pulse ox (lowest recorded): ________________
Date: _____________________
Tmax: _____________________
Date ______________________
SECTION VIII. LABORATORY VALUES
TEST
Result
Date
WBC (lowest)
____ / ____ / ____
% Neutrophils
____ / ____ / ____
% Lymphocytes
____ / ____ / ____
WBC (highest)
____ / ____ / ____
Hemoglobin (lowest)
____ / ____ / ____
Platelets (lowest)
____ / ____ / ____
Na (lowest)
____ / ____ / ____
Cr (highest)
____ / ____ / ____
Required dialysis □ Yes □ No
AST (highest)
____ / ____ / ____
ALT (highest)
____ / ____ / ____
Total bilirubin (highest)
____ / ____ / ____
Ferritin (highest)
____ / ____ / ____
CRP (highest)
____ / ____ / ____
ESR (highest)
____ / ____ / ____
SECTION IX. INVASIVE PROCEDURES
Document procedures done 14 days prior to the onset of symptoms above
Procedure name
Date
□ NG/OG tube placement
____ / ____ / ____
□ ET/OT/Other Intubation
____ / ____ / ____
□ Lumbar puncture
____ / ____ / ____
□ Thoracentesis
____ / ____ / ____
□ Paracentesis
____ / ____ / ____
□ Bronchoscopy
____ / ____ / ____
□ Central line placement
____ / ____ / ____
□ Arterial line placement
____ / ____ / ____
□ Other___________________ ____ / ____ / ____
□ Other___________________ ____ / ____ / ____
Page 5 of 8
Case ID# ____________
SECTION X. ANTIBIOTICS / IMMUNOSUPPRESION REGIMENS
Dose
Route
Start Date
Antibiotic /
immunosuppressive
therapy
□ Levofloxacin
(Levoquin)
□ Moxifloxacin
□ Ciprofloxacin
(Cipro)
□ Azithromycin
(Zithromax)
□ Erythromycin
□ Rifampin
□ Rifapentine
□ Linezolid
□ Tetracycline
□ Doxycycline
□ Quinupristin/
dalfopristin (Synercid)
□ Chemotherapy
regimen (specify):
___________
□ Radiation therapy
(specify):
___________
□ Systemic steroids
(specify):
___________
Other (specify):
___________
Other (specify):
___________
Other (specify):
___________
Other (specify):
___________
End Date
Check if
continued as
outpatient
Page 6 of 8
Case ID# ____________
SECTION XI. CLINICAL OUTCOMES
□ ICU Stay
a.) If ICU stay,
a. Number of days in ICU: __________ (count days where any time was spent in
ICU)
DISPOSITION:
□ S ll Hospitalized
□ Transferred to another facility (list:________________________________________)
□ Discharged Home
□ Unknown
□ Deceased
b.) If deceased,
a. Date of death: __________ (mm/dd/yyyy)
b. Was a post‐mortem examination performed? ___Yes ___No ____Unknown
i. If yes, are tissue specimens available? ____ Yes ____No ____ Unknown
DISCHARGE DIAGNOSIS
□ Legionellosis
□ Pneumonia
If yes, Etiology: ____________________ Lab Test(s): _______________________
□ Other Dx: _________________________________________________________________
Page 7 of 8
Case ID# ____________
SECTION XII. EXPOSURES
□ Hospitalized before; Date of admission: __ / __ / ____ ; Date of Discharge: __ / __ / ____
□ ICU stay; if yes # of days in ICU___________ days
□ Intubated
Discharge diagnosis: □ Legionellosis □ Pneumonia; e ology:_____________________
□ Other diagnosis; specify: _______________________________
□ Hospitalized before; Date of admission: __ / __ / ____ ; Date of Discharge: __ / __ / ____
□ ICU stay; if yes # of days in ICU___________ days
□ Intubated
Discharge diagnosis: □ Legionellosis □ Pneumonia; e ology:_____________________
□ Other diagnosis; specify: _______________________________
□ Hospitalized before; Date of admission: __ / __ / ____ ; Date of Discharge: __ / __ / ____
□ ICU stay; if yes # of days in ICU___________ days
□ Intubated
Discharge diagnosis: □ Legionellosis □ Pneumonia; etiology:_____________________
□ Other diagnosis; specify: _______________________________
OUTPATIENT VISITS to Hospital A or associated clinics (including rehab visits)
Did patient have any outpatient visits during the 2‐10 days prior to symptom onset?
_____ Yes _____ No _____ Unknown
If yes, list location of visits and name of clinic:
Building
Room#
Date(s) of Visit
Name of
Clinic
Campus
(e.g., Primary Care,
Cardiology)
Page 8 of 8
June 11, 2014
Form Approved
OMB No. 0920‐1011
Exp. Date 03/31/2017
Hypothesis Generating Questionnaire
Gastroenteritis
1
June 11, 2014
Form Approved
OMB No. 0920‐1011
Exp. Date 03/31/2017
Outbreak of Diarrheal Illness in American Samoa:
Hypothesis Generating Questionnaire for Gastroenteritis Complaints
Hi! My name is
. We are working with the Health department
to try and figure out what caused the outbreak of diarrhea. Could we please ask you a few
questions? Your answers will help prevent diarrhea in the future.
Your answers will be completely confidential. That means we will not share your personal
information with anybody else.
Thank you!!!
1) INTERVIEWER INFORMATION:
Interviewer name:
Date:
2) DEMOGRAPHIC INFORMATION:
Patient name:
Name (if not the patient):
Relationship to child (if patient is <18 years of age):
Sex:
M
F
DOB:
Nationality:
American Samoan
Western Samoan
Other Pacific Islander
Asian
White, non-Hispanic
Black, non-Hispanic
Unknown
Name of Village:
Number of people in household:
Number of adults:
Number of children:
2
June 11, 2014
Form Approved
OMB No. 0920‐1011
Exp. Date 03/31/2017
Place of work:_
3) CLINICAL SYMPTOMS:
According to our records, you came to the Emergency room for diarrhea on (DATE). Please
think back to the week before you got sick.
When did you first get sick (mm/dd/yyyy)?
On what day did diarrhea begin (mm /dd /yyyy)?
For how many days did you experience diarrhea? :
When at its worst, what was the total number of episodes of diarrhea you experienced in a 24
hour period?
- 1-3 per day
- 4-6 per day
- 5-10 per day
- 10+ per day
What symptoms did you have? : Circle all that apply.
- Fever
- Vomiting
- Poor feeding
- Irritable
- Bloody diarrhea
- Non-bloody diarrhea
- Watery diarrhea
- Fatigue/Weakness
- Chills
- Headache
- Abdominal cramps
- Nausea
- Bodyaches
What was the first place you went to seek treatment?
- Emergency room
- Local clinic
- Village healer
- Other:
3
June 11, 2014
Form Approved
OMB No. 0920‐1011
Exp. Date 03/31/2017
Did you take any medications for the diarrhea?
Over the counter:
From the hospital:
Yes
Yes
No
No
/Name:
/Name:
Do you use any at-home remedies for diarrhea?
Yes
No /Name:
Did you hear about diarrhea from family/friends recently?
Yes
No
Did you hear about diarrhea from on TV/in the newspaper recently?
Yes
No
How long after you first got sick did you seek medical treatment?
- Less than 1 day
- 1 – 2 days
- 3 – 4 days
- 5 – 6 days
- 7 days or more
What prompted you to go to the emergency room? Circle all that apply.
- Diarrhea
- Dehydration
- Fever
- Stomach / gut pain
- Unable to eat
- To get medicine
- Worried about ameba
- Friend or family member suggested going
- Other:
4) TRAVEL / EVENT EXPOSURES:
Did you attend flag day?
Yes
No
In the week before illness, did you travel anywhere outside the village?
Yes
No
If yes, where?
Other village(s): (Village name(s):
Off-island (Name of location):
In the week before illness, did you have contact with anyone who traveled:
Outside the village: Yes No
Off-island: Yes No
4
June 11, 2014
Form Approved
OMB No. 0920‐1011
Exp. Date 03/31/2017
In the week before illness, were you exposed to a school or child-care facility?
In the week before illness, were you exposed to any flies?
Is your home screened? Yes
Yes
Yes
No
No
Do you have a refrigerator? Yes
No
In the week before illness, did you attend any special events where food was served or catered
(weddings, community meetings, church events, etc.)? Yes No
If yes:
#1 Type of event:
#1 Was there a sink with soap and water to wash your hands? Yes No
#2 Type of event:
#2 Was there a sink with soap and water to wash your hands?
Yes
No
In the week before illness, did you go swimming or have other recreational water exposures
(fishing, etc.)? Yes No
If yes, please describe:
5) HOUSEHOLD WATER EXPOSURES:
What is the water supply source for your home or residence? Circle all that apply.
- ASPA water
- Village water
- Rain water
- Vending machines
- Bottled water
- Other:
If multiple sources, what source is usually used for each?
Drinking:
Cooking:
Bathing:
Washing clothing:
Cleaning:
washing:
Hand
5
June 11, 2014
Form Approved
OMB No. 0920‐1011
Exp. Date 03/31/2017
Where do you typically wash your hands at home?
When do you typically wash your hands at home?
When you don’t wash your hands at home, what are some reasons why?
Does the household usually boil or filter water before use for cooking?
- Boiling
- Filtering
- No treatment
Does the household usually boil or filter water before use for drinking?
- Boiling
- Filtering
- No treatment
6) SEWAGE EXPOSURES:
What type of sewage disposal does your house have?
- ASPA sewage
- Septic Tank
- Cesspool
- Nothing
- Other :
41. How do you dispose of trash?
- ASPA
- Self-disposal
- Other:
IF ASPA:
How many days per week is trash collected by ASPA?
days per week
IF SELF DISPOSAL:
How many days per week is trash taken outside the house?
6
June 11, 2014
Form Approved
OMB No. 0920‐1011
Exp. Date 03/31/2017
days per week
How many days per week is trash taken off the property?
days per week
Where do you take the trash to:
7) FOOD EXPOSURES:
What do you eat on a typical day?
Breakfast
What do you eat?
Where do you eat?
Lunch
What do you eat?
Where do you eat?
Dinner
What do you eat?
Where do you eat?
Snacks
What do you eat?
Where do you eat?
Drinks
What do you drink?
Where do you usually shop for groceries?
7
June 11, 2014
Form Approved
OMB No. 0920‐1011
Exp. Date 03/31/2017
What restaurants do you usually go to?
8) ILL CONTACTS:
Do you know anyone else who is ill? Yes No
#1 Relation to you:
#1 Does this person live with you?:
#1 Village:
#2 Relation to you:_
#2 Does this person live with you?:
#2 Village:
#3 Relation to you:_
#3 Does this person live with you?:
#3 Village:
#4 Relation to you:
#4 Does this person live with you?:
#4 Village:
#5 Relation to you:
#5 Does this person live with you?:
#5 Village:
9) PERSONAL OPINION
How do you think you got sick?
Is there anything else you would like to share with us, relating to the diarrhea outbreak?
THANK YOU SO MUCH FOR YOUR TIME!!!
We truly appreciate your talking to us today.
8
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Household Line Listing
Measles
Public reporting burden of this collection of information is estimated to average 55 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-74 Atlanta, Georgia
30333; ATTN: PRA (0920-1011)
Measles Case ID # ________
Number of Persons Living in the House _____
1
2
3
4
5
6
7
8
Date of
Birth
__ /_ __/_ __
__ /_ __/_ __
__ /_ __/_ __
__ /_ __/_ __
__ /_ __/_ __
__ /_ __/_ __
__ /_ __/_ __
__ /_ __/_ __
Age
(y, m)
Number of Rooms in the House ____
Sex
__ _/__ _/__ _
HH No.
List Dates of HH Visits __ _/__ _/__ _
First Name
Last Name
1
Case-Patient’s Name ________________________________
__ _/__ _/__ _
Mother’s First
Name (If age
39 or less)
Fever and
rash in the
last 2
months
(May/June)?
Yes
Date of onset
__ _/__ _/__ _
No
Yes
Date of onset
__ _/__ _/__ _
No
Yes
Date of onset
__ _/__ _/__ _
No
Yes
Date of onset
__ _/__ _/__ _
No
Yes
Date of onset
__ _/__ _/__ _
No
Yes
Date of onset
__ _/__ _/__ _
No
Yes
Date of onset
__ _/__ _/__ _
No
Yes
Date of onset
__ _/__ _/__ _
No
Household Location: Municipality _______________
Had
measles
before
this
year?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
MMR
Doses
0___
1___
2___
3___
0___
1___
2___
3___
0___
1___
2___
3___
0___
1___
2___
3___
0___
1___
2___
3___
0___
1___
2___
3___
0___
1___
2___
3___
0___
1___
2___
3___
MMR
Dates
Doses
obtained
(check one)
__ _/_ __/_ __
__ _/_ __/_ __
__ _/_ __/_ __
__ by history
__ from record
__ _/_ __/_ __
__ _/_ __/_ __
__ _/_ __/_ __
_ by history
_ from record
__ _/_ __/_ __
__ _/_ __/_ __
__ _/_ __/_ __
_ by history
_ from record
__ _/_ __/_ __
__ _/_ __/_ __
__ _/_ __/_ __
_ by history
_ from record
__ _/_ __/_ __
__ _/_ __/_ __
__ _/_ __/_ __
_ by history
_ from record
__ _/_ __/_ __
__ _/_ __/_ __
__ _/_ __/_ __
_ by history
_ from record
__ _/_ __/_ __
__ _/_ __/_ __
__ _/_ __/_ __
_ by history
_ from record
__ _/_ __/_ __
__ _/_ __/_ __
__ _/_ __/_ __
_ by history
_ from record
Village _______________
Lived/slept at least one night
in the HH from 3 days prior
and 3 days after rash onset of
1st case?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
9
10
11
12
13
14
15
16
17
2
Case-Patient’s Name ________________________________
Date of
Birth
__ /_ __/_ __
__ /_ __/_ __
__ /_ __/_ __
__ /_ __/_ __
__ /_ __/_ __
__ /_ __/_ __
__ /_ __/_ __
__ /_ __/_ __
__ /_ __/_ __
Age
(y, m)
First Name
Last Name
Sex
HH No.
Measles Case ID # ________
Mother’s First
Name (If age
39 or less)
Fever and
rash in the
last 2
months
(May/June)?
Yes
Date of onset
__ _/__ _/__ _
No
Yes
Date of onset
__ _/__ _/__ _
No
Yes
Date of onset
__ _/__ _/__ _
No
Yes
Date of onset
__ _/__ _/__ _
No
Yes
Date of onset
__ _/__ _/__ _
No
Yes
Date of onset
__ _/__ _/__ _
No
Yes
Date of onset
__ _/__ _/__ _
No
Yes
Date of onset
__ _/__ _/__ _
No
Yes
Date of onset
__ _/__ _/__ _
No
Had
measles
before
this
year?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
MMR
Doses
0___
1___
2___
3___
0___
1___
2___
3___
0___
1___
2___
3___
0___
1___
2___
3___
0___
1___
2___
3___
0___
1___
2___
3___
0___
1___
2___
3___
0___
1___
2___
3___
0___
1___
2___
3___
MMR
Dates
Doses
obtained
(check one)
__ _/_ __/_ __
__ _/_ __/_ __
__ _/_ __/_ __
_ by history
_ from record
__ _/_ __/_ __
__ _/_ __/_ __
__ _/_ __/_ __
__ by history
__ from record
__ _/_ __/_ __
__ _/_ __/_ __
__ _/_ __/_ __
_ by history
_ from record
__ _/_ __/_ __
__ _/_ __/_ __
__ _/_ __/_ __
_ by history
_ from record
__ _/_ __/_ __
__ _/_ __/_ __
__ _/_ __/_ __
_ by history
_ from record
__ _/_ __/_ __
__ _/_ __/_ __
__ _/_ __/_ __
_ by history
_ from record
__ _/_ __/_ __
__ _/_ __/_ __
__ _/_ __/_ __
_ by history
_ from record
__ _/_ __/_ __
__ _/_ __/_ __
__ _/_ __/_ __
_ by history
_ from record
__ _/_ __/_ __
__ _/_ __/_ __
__ _/_ __/_ __
_ by history
_ from record
Lived/slept at least one night
in the HH from 3 days prior
and 3 days after rash onset of
1st case?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
18
3
Case-Patient’s Name ________________________________
Date of
Birth
__ /_ __/_ __
Age
(y, m)
First Name
Last Name
Sex
HH No.
Measles Case ID # ________
Mother’s First
Name (If age
39 or less)
Fever and
rash in the
last 2
months
(May/June)?
Yes
Date of onset
__ _/__ _/__ _
No
Had
measles
before
this
year?
Yes
No
MMR
Doses
0___
1___
2___
3___
MMR
Dates
__ _/_ __/_ __
__ _/_ __/_ __
__ _/_ __/_ __
Doses
obtained
(check one)
_ by history
_ from record
Lived/slept at least one night
in the HH from 3 days prior
and 3 days after rash onset of
1st case?
Yes
No
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Dengue and chikungunya report form
Public reporting burden of this collection of information is estimated to average 5 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-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
DENGUE & CHIKUNGUNYA REPORT FORM
U.S. Virgin Islands Department of Health
Charles Harwood Complex, 3500 Estate Richmond
Christiansted, St. Croix, USVI 00820-4370
Tel. (340) 773-1311 x3241, Fax (340) 718-1508
Case number
Specimen #
SAN ID
GCODE
Days post onset (DPO) Type
Date Received
S3
S2
S4
No
Today’s date: _______________
Day/Month/Year
Specimen #
S1
SUSPECTED CHIK? Yes
Days post onset (DPO)
Type
Date Received
Please read and complete ALL sections
Patient Data
Hospitalized due to this illness: No
→ Hospital Name:
Yes
Record Number:
Fatal:
Name of Patient:
Last Name
First Name
Yes
Middle Name or Initial
No
Unk
Mental status changes:
If patient is a minor, name of father or primary caregiver:
Last Name
First Name
Home (Physical) Address
Middle Name or Initial
Yes
No
Unk
Physician who referred this case
Home address here
Name of Healthcare Provider:
Tel:
Fax:
Email:
Do you want to receive laboratory results via Fax or Email?
City:
Zip code:
Tel:
-
Other Tel:
Residence is close to:
Work address:
Patient’s Demographic Information
Date of Birth:
Age:
months Sex:
or Age:
years
Who filled out this form?
M
F
Pregnant: Y
N
UNK
Weeks pregnant (gestation):
Day/Month/Year
Name (complete)
Relationship with patient:
Tel:
Fax:
Email:
Must have the following information for sample processing
Day/Month/Year
Country of birth
How long have you lived in this city?
Date of first symptom:
During the 14 days before onset of illness, did you TRAVEL to other cities or countries?
Date specimen taken:
First sample
Yes, another country
Yes, another city
No
Unknown
WHERE did you TRAVEL?
Second sample
Are there any sick contacts in your household?
Yes
No
PLEASE indicate below the signs and symptoms that the patient had at the time of illness
Yes
No
Unk
Evidence of capillary leak
Lowest
Fever lasting 2-7 days……………......
Fever (>38ºC/101ºF)………………......
Platelets ≤100,000/mm3………..….....
Warning signs
hematocrit
Highest
hematocrit
Lowest
serum
(%)
Persistent vomiting...................................
(%)
Abdominal pain/Tenderness…………..
albumin
Mucosal bleeding …………………….....
Lowest serum protein
Lethargy, restlessness……….…………...
Platelet count:
Lowest blood pressure (SBP/DBP)
Any hemorrhagic manifestation
Petechiae………………………..
Lowest pulse pressure (systolic - diastolic)
Liver enlargement >2cm………………..
/
Pleural or abdominal effusion………….
Lowest white blood cell count (WBC)
Purpura/Ecchymosis…………..
Symptoms
Yes
Yes
Additional symptoms
No
Unk
Diarrhea……………………………...……..
Vomit with blood……………….
Rapid, weak pulse……………...
Blood in stool……………………
Cough…………………………………….…
Pallor or cool skin……………….
Nasal bleeding…………………
Conjunctivitis……………………………....
Chills………………………….……
Nasal congestion…………………………
Rash…...........................................
Sore throat………………………………....
Headache……………….……….
Jaundice………………………..................
Eye pain…………………………..
Convulsion or coma……………………..
Body (muscle/bone) pain…….
Nausea and vomiting (occasional)…..
Joint pain…………………………
Arthritis (Swollen joints)…………………..
Anorexia……………………….....
Missed school/work due to this illness.
Bleeding gums………………….
Blood in urine…………………...
Vaginal bleeding………………
Positive urinalysis……………....
(over 5 RBC/hpf or positive for blood)
Tourniquet test
Pos
Neg
Not done
Unable to walk during this illness……..
No
Unk
Form Approved
OMB No. 0920-1011
Expiration 03/31/2017
Suspected Chikungunya Case Questionnaire
August 16, 2014
Interviewer:______________ Date of Interview: ___/___/_____
Name of person/parent giving consent:_____________________ □ Refused Interview
If case-patient is not available, ask for an alternate contact number or time to call back to speak with case
patient. Alternate number _______________ Alternate day/time _________________
1.) We have your age (your child’s age) as ______, is this correct? [If no] What is the correct age? ____
a. [For parents <17 year old child] Can I ask what is your age and sex?
Age in years____ Sex: □ Male □ Female
2.) Per our records, a sample was taken for chikungunya testing on __ __ /__ __ /2014 , does this sound correct?
□ Yes □ No
[If this is not correct] Can you recall which date the sample was drawn? __ __ /__ __ /2014
3.) Besides yourself (or your child), has anyone else in your household had similar symptoms?
□ Yes (go to question 4)
□ No (go to question 5)
□ Don’t know (go to question 5)
4.) How many of these household members with similar symptoms sought medical care? _______
5.) How long did the initial joint pain last when you were tested for Chikungunya? _________ days after
symptoms started.
6.) Do you have any joint pain (i.e., pain in your wrists, ankles, hands or feet) or joint swelling today that you
think might be related to your recent illness?
□ Yes (go to question 8)
□ No (go to question 7)
□ Don’t know (go to question 7)
7.) Have you (or your child) had any joint pain or swelling in the last week that you think might be related to your
recent illness?
□ Yes (go to question 8)
□ No (go to question 9)
□ Don’t know
8.) How often do you (your child) experience joint pain or swelling that you think might be related to your recent
illness?
□ Daily
□ Two to three times per week
□ Once per week
□ Less than once per week
□ Don’t know
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 Reports Clearance Officer; 1600 Clifton Road NE, MS D‐74 Atlanta, Georgia 30333; ATTN: PRA (0920‐1011)
9.) What is your current employment status?
□ Working (go to question 10)
□ Retired (go to question 13)
□ Not Working (go to question 13)
□ Child (go to question 15)
□ Refused
10.) In the time since you have visited the doctor for suspected chikungunya, have you missed time from work
because of your illness?
□ Yes (go to question 11)
□ No (go to question 16)
11.) Have you (your parent) returned to work?
□ Yes (go to question 12)
□ No (go to question 16)
12.) How many days of work did you miss? ______ (go to question 16)
13.) In the time since you visited the doctor for suspected chikungunya, have you been unable to do your normal
chores and activities?
□ Yes (go to question 14)
□ No (go to question 16)
14.) How many days of chores/activities have you missed? ______ (go to question 16)
15.) Have you (or has your parent) had to miss work to care for your sick child (or you)?
□ Yes (go to question 11)
□ No (go to question 16)
16.) Were you been hospitalized due to your illness for which you were tested for chikungunya?
□ Yes (go to question 17)
□ No (go to question 18)
17.) How many days were you hospitalized? ________
18.) Did you seek additional medical attention following the date your sample was drawn for suspected
chikungunya?
□ Yes (go to question 19)
□ No (go to question 20)
19.) How many times did you seek medical attention? ________ healthcare visits
20.) Do you have a history of chronic joint pain prior to being diagnosed with chikungunya?
□ Yes
□ No
Thank you for answering our additional question. The information you have provide will let us learn more about
chikungunya and how the disease is affecting you and other people in your community.
Would you be willing for the health department to contact you again related to your illness?
Finally, do you have any questions for me?
□ Yes
□ No
CHIKUNGUNYA INVESTIGATION — HOUSEHOLD INTERVIEW FORM
Form Approved
OMB No. 0920‐1011
Exp. Date 03/31/2017
TEAM #:
GPS Coordinates:
.
DATE:
/
,
_/
.
Household ID (e.g., SJ-1-A):
-
-
SANID of lab-positive case:
How many people live in this house?
people
List all members of household below put yourself first.
Head of household contact number to facilitate return of test results:_
Name (First, Paternal, Maternal)
1
Age
Gender
Participate?
M/F
Yes / No
2
3
M/F
4
5
6
Yes / No
M/F
Yes / No
M/F
Yes / No
M/F
Yes / No
M/F
Yes / No
7
8
Place sticker here
M/F
Yes / No
M/F
Yes / No
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‐74 Atlanta, Georgia 30333; ATTN: PRA (0920‐1011)
CHIKUNGUNYA INVESTIGATION — HOUSEHOLD INTERVIEW FORM
Household Characteristics
Housing type (check only one):
□Public housing
□ One story house
□ Two story house □
Apartment/condo building
□ Temporary shelter
Has anyone in your immediate household traveled outside of Puerto Rico in the past 3 months?
Has anyone in your household been sick in the past 3 months?
□ Yes
□ Yes
□ No
Does your home have screened windows and doors?
□ All rooms
Do you regularly use air conditioning in your home?
□ Yes, in all rooms □ Yes, but only in some rooms
Do you regularly leave your doors or windows open?
□ Daytime only
Do you use mosquito coils in your house or patio?
□
Yes
Do you use citronela in your house or patio to keep mosquitoes away?
□ Some rooms
□ No
□ No
□ Night-time only □ Always □ Never
□ No
□
Yes
□ No
Notes:
□ No
Form Approved
OMB No. 0920‐1011
Exp. Date 03/31/2017
Chikungunya Investigation ‐ Individual Interview Form
Team #:
Interviewer:
Date of interview:
Individual ID (e.g., SJ-1-A-1):
-
-
/_
/_
-
1. Name:
First (given)
2. Gender:
□ Male □Female
Initial
Paternal
Maternal
3. Date of Birth (MM/DD/YYYY):
4. How long have you been living in Puerto Rico?
/
/
years
5. Have you been told by a clinician that you have any of the following medical conditions?
□ Diabetes □ High blood pressure
□ Stroke □ Kidney disease
□ Asthma □ Lung disease
□ Heart disease
□ Liver disease
□ Joint disease/arthritis
□ High cholesterol
□ Thyroid disease
□ Cancer
6. Do you take any of the following medications daily:
□ NSAID (e.g., aspirin, Iburpofen) □ Corticosteroids
□ Antibiotics
□ No
7. Have you experiencing any new illnesses in the past 3 months? □Yes
(If more than one illness episode, detail each additional episode in Notes.)
7a. If yes, first day of illness (MM/DD/YYYY):
/
/
_
7b. What symptoms did you have (check all that apply)?
□ Fever
□ Muscle pain
□ Headache
□ Runny nose
□ Chills
□ Joint pain
□ Pain behind eyes
□ Sore throat
□ Nausea/Vomiting
□ Skin rash
□ Abdominal pain
□ Calf pain
□ Diarrhea
□ Red eyes
□ Cough
□ Arthritis (red, swollen
joints)
□ Minor bleeding (e.g., petechia, gum bleed, nosebleed, severe bruising)
□ Major bleeding (e.g., vomiting blood, coughing up blood, blood in stool, heavy menses)
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‐74 Atlanta, Georgia 30333; ATTN: PRA
(0920‐1011)
□ 7b-1. If you had joint pain, indicate the locations where you had the pain
7c. How long did this illness last?
days
□ Yes
7d. Did you go to the doctor because of this illness?
□ No
7d-1. If yes, Name of hospital/clinic:
7d-2. What was the diagnosis?
□ Viral syndrome □ I don’t know
□Chikungunya
□ Other:
7d-3. Were you hospitalized for this illness?
□ Dengue
□ Yes □
No
7d-3a. If yes, Hospital Name:
7d-3b. Days in the hospital:
days
8. Have you used mosquito repellent in the past month?
9. Have you slept under a bednet in the past month?
□ Daily
□ Yes
□ Weekly □ Never
□ No
10. Have you traveled outside of Puerto Rico in the past 3 months? □ Yes
□ No
10a. If yes, specify where and date of return to Puerto Rico for the most recent trip:
□ United States (excluding USVI) □ Dominican Republic
□Other:
Date of return to PR (MM/DD/YYYY):
NOTES:
/
/
□Caribbean cruise
Form Approved
OMB No. 0920-1011
SISTEMA CENTINELA DE VIGILANCIA DE CHIKUNGUNYA (CHIKSS)
REPORTE DE CASO
Exp.: 3/31/2014
REVISADO:
FIEBRE + POLIARTRALGIA + NO TOS
(iniciales)
Fecha de hoy:
/
/
Día Mes Año
SOLAMENTE PARA USO DEL LABORATORIO
Número de caso
Espécimen # Días después 1er síntoma Tipo Fecha recibido Espécimen # Días después 1er síntoma Tipo Fecha recibido
S1
GCODE
SAN ID
S3
S2
S4
Favor de leer y completar TODAS las secciones
Datos del paciente
Se hospitalizó por esta enfermedad:
Sí → Nombre del hospital:
No
Número de expediente:
Nombre del Paciente:
Apellido paterno
Apellido materno
Nombre
Segundo nombre / inicial
Falleció:
Sí
No
No sabe
Cambios en estado mental:
Si el paciente es un menor, nombre del padre o encargado:
Apellido paterno
Nombre
Apellido materno
Dirección residencial completa (Física)
Sí
Segundo nombre / inicial
No
No sabe
Médico o proveedor que ordenó la prueba de chikungunya
Dirección de la casa aquí
Nombre:
Hospital:
Municipio:
Código postal:
Tel.:
-
Otro Tel.:
CDT San José
Bella Vista
HIMA Fajardo
Buen Samaritano
San Jorge Children’s
HIMA Caguas
Susoni
Vive cerca de:
Nombre y dirección del trabajo:
Información demográfica del paciente
Fecha nacimiento:
/
Día
/
Mes
Edad:
meses
ó Edad:
Sexo:
años ¿Encinta?:
Año
¿Quién llenó este formulario?
M
F
Sí
No
Doctor(a)
NS
Enfermero(a)
OTRO
Semanas de gestación
Datos indispensables para procesar las muestras
Datos adicionales del paciente
¿Cuántos años ha vivido en este municipio?
Día
Fecha del primer síntoma:
Mes
/
Año
/
¿En qué país nació?
¿Durante los 14 días antes de enfermar, ¿VIAJÓ a otro país o pueblo?
Sí, otro país
Fecha de toma de muestra:
/
/
Sí, otro pueblo
No
No sabe
¿A dónde viajó?
¿Desde que se enfermó, faltó a la escuela/trabajo?
SI
NO
NO APLICA
POR FAVOR indique todos los signos y síntomas del paciente
Sí
No
No sabe
Fiebre durante 2 – 7 días ........................
Fiebre (>38ºC/101ºF)................................
Señales de advertencia
Presión arterial (SBP/DBP) :
Conteo
Letargia/inquietud….………………....
Agrandamiento del hígado > 2cm…
de plaquetas:
Efusión pleural o abdominal…………
Petequias……………………………….
Síntomas adicionales
Equimosis o Cardenales………….....
Diarrea…………………………………..
Vómito con sangre…………………...
Hemorragia nasal…………………....
Pulso acelerado y débil…………...…….
Conjuntivitis…………………………….
Hemorragia de las encías………….
Palidez o piel fría ………………………....
Sangre en la orina……………………
Congestión nasal……………………..
Erupción de la piel………………………..
(sobre 5 RBC/hpf o positivo para sangre)
CONTINÚE AL DORSO!!
Dolor de cabeza…………………………..
Dolor en los ojos…………………………...
Dolor en el cuerpo ……………………….
Dolor de coyunturas ……………………..
Anorexia…………………………………….
Sí
No
No sabe
Tos…………………………………….....
Sangre en la excreta…………………
Síntomas
Urianálisis positivo……………………
No sabe
Sangrado de las mucosas …………..
Conteo de glóbulos blancos (WBC):
Hemorragia vaginal…………………
No
Dolor abdominal/sensibilidad ……..
/
Hematocrito (%):
Alguna manifestación hemorrágica
Sí
Vómito persistente ......……………. ...
Medidas Clínicas
Dolor de garganta……………………
Ictericia………………………………..
Convulsión o coma………………….
Náusea y vómito (ocasional)…….
Artritis (coyunturas hinchadas)……
No puede caminar ………………….
Este formulario está autorizado por la Ley 42 USC 241 del Servicio de Salud Pública. Contestar este formulario es voluntario, pero, se necesita la cooperación del paciente para el estudio y
control de enfermedades. Contestar las preguntas toma aproximadamente 15 minutos por formulario. Envíe sus comentarios y sugerencias sobre el tiempo que toma llenar el formulario o sobre
cualquier otro aspecto de la recopilación de información a: CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011).
Los círculos a continuación representan las coyunturas en el cuerpo humano,
marque con una “X” las áreas donde el paciente tiene DOLOR
Columna vertebral
DERECHA
IZQUIERDA
Los círculos a continuación representan las coyunturas en el cuerpo humano,
marque con una “X” las áreas donde el paciente tiene LAS COYUNTURAS ROJAS
E HINCHADAS
Columna vertebral
DERECHA
IZQUIERDA
ESPACIO PARA ETIQUETA
DEL LABORATORIO
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Appendix 1:
VIRAL HEMORHAGIC FEVER
CASE INVESTIGATION FORM
Public reporting burden of this collection of information is estimated to average 25 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-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
VIRAL HEMORHAGIC FEVER
CASE INVESTIGATION FORM
Outbreak
Case ID:
Health
Facility
Case ID:
Date of Case Report: ____/____/_____ (D, M, Yr)
Section 1.
Patient Information
Patient’s Surname: ______________________ Other Names:____________________________
Age: _______
Years
Months
Gender:
Male
Female
Phone Number of Patient/Family Member:_____________________ Owner of Phone: ________________
Status of Patient at Time of This Case Report:
Alive
Dead
If dead, Date of Death: ___/___/____ (D, M, Yr)
Permanent Residence:
Head of Household: __________________________ Village/Town: _______________________ Parish: __________________________
Country of Residence: _________________ District: ____________________________ Sub-County: ____________________________
Occupation:
Farmer
Butcher
Hunter/trader of game meat
Miner
Religious leader
Housewife
Pupil/student
Child
Businessman/woman; type of business: _____________________
Transporter; type of transport: ___________________________
Healthcare worker; position: _________________ healthcare facility: ___________________
Traditional/spiritual healer
Other; please specify occupation: _____________________________________________________
Location Where Patient Became Ill:
Village/Town: _________________________ District: _________________________ Sub-County: _________________________
GPS Coordinates at House: latitude: __________________ longitude: ________________________
If different from permanent residence, Dates residing at this location: ___/___/____ - ___/___/____ (D, M, Yr)
Section 2.
Clinical Signs and Symptoms
Date of Initial Symptom Onset:
____/____/______ (D, M, Yr)
Please tick an answer for ALL symptoms indicating if they occurred during this illness between symptom onset and case detection:
Fever
If yes, Temp: ____º C Source:
Yes
Axillary
Vomiting/nausea
Diarrhea
Intense fatigue/general weakness
Anorexia/loss of appetite
Abdominal pain
Chest pain
Muscle pain
Joint pain
Headache
Cough
Difficulty breathing
Difficulty swallowing
Sore throat
Jaundice (yellow eyes/gums/skin)
Conjunctivitis (red eyes)
Skin rash
Hiccups
Pain behind eyes/sensitive to light
Coma/unconscious
Confused or disoriented
Section 3.
Oral
No
Unk
Rectal
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unexplained bleeding from any site
If Yes:
Bleeding of the gums
Bleeding from injection site
Nose bleed (epistaxis)
Bloody or black stools (melena)
Fresh/red blood in vomit (hematemesis)
Digested blood/“coffee grounds” in vomit
Coughing up blood (hemoptysis)
Bleeding from vagina,
other than menstruation
Bruising of the skin
(petechiae/ecchymosis)
Blood in urine (hematuria)
Yes
No
Unk
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Yes
No
Unk
Yes
No
Unk
Other hemorrhagic symptoms
Yes
No
Unk
If yes, please specify: ___________________________
Other non-hemorrhagic clinical symptoms:
Yes
No
If yes, please specifiy: ___________________________
Unk
Hospitalization Information
At the time of this case report, is the patient hospitalized or currently being admitted to the hospital?
If yes, Date of Hospital Admission: ____/____/_____ (D, M, Yr)
Yes
No
Health Facility Name: ________________________________________
Village/Town: __________________________ District: _______________________ Sub-County: _________________________
Is the patient in isolation or currently being placed there?
Yes
No
If yes, date of isolation: ____/____/_____ (D, M, Yr)
Was the patient hospitalized or did he/she visit a health clinic previously for this illness?
Yes
No
Unk
If yes, please complete a line of information for each previous hospitalization:
Dates of Hospitalization
Health Facility Name
Village
District
Was the patient isolated?
___/___/____ - ___/___/____ (D, M, Yr)
Yes
No
___/___/____ - ___/___/____ (D, M, Yr)
Yes
No
Outbreak
Case ID:
Section 4.
Epidemiological Risk Factors and Exposures
IN THE PAST ONE(1) MONTH PRIOR TO SYMPTOM ONSET:
1. Did the patient have contact with a known or suspect case, or with any sick person before becoming ill?
If yes, please complete one line of information for each sick source case:
Name of Source
Case
Relation to
Patient
Dates of Exposure
Village
District
No
Was the person dead or alive ?
Unk
Contact
Types**
(D, M, Yr)
Alive
Dead, date of death: ___/___/____ (D, M, Y)
Alive
Dead, date of death: ___/___/____ (D, M, Y)
Alive
Dead, date of death: ___/___/____ (D, M, Y)
___/___/___ - ___/___/___
___/___/___ - ___/___/___
___/___/___ - ___/___/___
**Contact Types:
(list all that apply)
Yes
1 – Touched the body fluids of the case (blood, vomit, saliva, urine, feces)
2 – Had direct physical contact with the body of the case (alive or dead)
3 – Touched or shared the linens, clothes, or dishes/eating utensils of the case
4 – Slept, ate, or spent time in the same household or room as the case
2. Did the patient attend a funeral before becoming ill?
Yes
No
Unk
If yes, please complete one line of information for each funeral attended:
Name of Deceased Person Relation to Patient
Dates of Funeral
Attendance (D, M, Yr)
Village
District
Did the patient participate
(carry or touch the body)?
___/___/____ - ___/___/____
Yes
No
___/___/____ - ___/___/____
Yes
No
3. Did the patient travel outside their home or village/town before becoming ill?
Yes
No
Unk
If yes, Village: __________________________ District: ______________________ Date(s): ___/___/____ - ___/___/____
4. Was the patient hospitalized or did he/she go to a clinic or visit anyone in the hospital before this illness?
If yes, Patient Visited: ____________________ Date(s): ___/___/____ - ___/___/____ (D, M, Yr)
Yes
(D, M, Yr)
No
Unk
Health Facility Name: _________________________ Village: _____________________ District: _______________________
5. Did the patient consult a traditional/spiritual healer before becoming ill?
Yes
No
Unk
If yes, Name of Healer: _____________________Village: _______________ District: _____________ Date: ___/___/____ (D, M, Yr)
6. Did the patient have direct contact (hunt, touch, eat) with animals or uncooked meat before becoming ill?
If yes, please tick all that apply:
Animal:
Status (check one only):
Bats or bat feces/urine
Healthy
Sick/Dead
Primates (monkeys)
Healthy
Sick/Dead
Rodents or rodent feces/urine
Healthy
Sick/Dead
Pigs
Healthy
Sick/Dead
Chickens or wild birds
Healthy
Sick/Dead
Cows, goats, or sheep
Healthy
Sick/Dead
Other; specify______________
Healthy
Sick/Dead
7. Did the patient get bitten by a tick in the past 2 weeks?
Section 5.
Yes
No
Yes
No
Unk
Unk
Clinical Specimens and Laboratory Testing
Specimen/shipping instructions: Label sample with patient name, date of collection, and case ID
Send sample cold with a cold/ice pack, and packaged appropriately.
Collect whole blood in a purple top (EDTA) tube – green or red top tubes
acceptable if purple not available
Preferred sample volume = 4ml (minimum sample volume = 2ml)
Has this patient had a sample submitted previously?
Sample 1:
Yes
Do not complete
UVRI Only
Sample 2:
Sample Collection Date: ____/____/______
(D, M, Yr)
Sample Type:
Whole Blood
Post-mortem heart blood
Skin biopsy
Other specimen type, specify: ________________
Section 6.
No
Do not complete
UVRI Only
Sample Collection Date: ____/____/______ (D, M, Yr)
Sample Type:
Whole Blood
Post-mortem heart blood
Skin biopsy
Other specimen type, specify: ________________
Case Report Form Completed by:
Name: ______________________________ Phone: _________________________ E-mail: _______________________________
Position: _____________________________ District: _____________________ Health Facility: ____________________________
Information provided by:
Patient
Proxy; If proxy, Name:______________________ Relation to Patient: ___________________
Outbreak
Case ID:
Case
Name:
**If the patient is deceased or has already recovered from illness, please fill out the next section.
**If the patient is currently admitted to the hospital, leave the next section blank (it will be completed upon discharge)
Section 7.
Patient Outcome Information
Please fill out this section at the time of patient recovery and discharge from the hospital OR at the time of patient death.
Date Outcome Information Completed: ____/____/_____ (D, M, Yr)
Final Status of the Patient:
Alive
Dead
Did the patient have signs of unexplained bleeding at any time during their illness?
Yes
No
Unk
If yes, please specify: _______________________________________________________________________________
If the patient has recovered and been discharged from the hospital:
Name of hospital discharged from: _______________________________ District: _________________________________
If the patient was isolated, Date of discharge from the isolation ward: ____/____/______ (D, M, Yr)
Date of discharge from the hospital: ____/____/______
(D, M, Yr)
If the patient is dead:
Date of Death: ____/____/______ (D, M, Yr)
Place of Death:
Community
Hospital: _______________________
Other: ________________________________
Village: _______________________ District: _________________________ Sub-County: _______________________
Date of Funeral/Burial: ____/____/______ (D, M, Yr)
Funeral conducted by:
Family/community
Outbreak burial team
Place of Funeral/Burial:
Village: _______________________ District: _________________________ Sub-County: _______________________
Please tick an answer for ALL symptoms indicating if they occurred at any time during this illness including during hospitalization:
Fever
If yes, Temp: ____º C Source:
Yes
Axillary
Vomiting/nausea
Diarrhea
Intense fatigue/general weakness
Anorexia/loss of appetite
Abdominal pain
Chest pain
Muscle pain
Joint pain
Headache
Cough
Difficulty breathing
Difficulty swallowing
Sore throat
Jaundice (yellow eyes/gums/skin)
Conjunctivitis (red eyes)
Skin rash
Hiccups
Pain behind eyes/sensitive to light
Coma/unconscious
Confused or disoriented
Oral
No
Unk
Rectal
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Other non-hemorrhagic clinical symptoms:
Yes
No
If yes, please specifiy: ____________________________
Unk
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Appendix 2:
CONTACT TRACING FORM
Public reporting burden of this collection of information is estimated to average 3 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-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
*8,1($ VIRAL HEMORRHAGIC FEVER CONTACT LISTING FORM
Case Information
UVRI/MoH
Case ID
Surname
Other Names
Head of Household
Village
Sub-County
District
Date of
Symptom
Onset
Date of
Admission to
Isolation
Date of Death
**For all information on location, please list information on where the contact will be residing for the next month.
Contact Information
Surname
Other
Names
Sex Age Relation
(M/F) (yrs) to Case
Date of
Last
Contact
with Case
Type of
Contact
(1,2,3,4)*
list all
Head of
Household
Village
District
SubCounty
LC1
Chairman
Phone Number
Healthcare
Worker (Y/N)
If yes, what
facility?
*Types of Contact:
1 = Touched the body fluids of the case (blood, vomit, saliva, urine, feces)
2 = Had direct physical contact with the body of the case (alive or dead)
3 = Touched or shared the linens, clothes, or dishes/eating utensils of the case
4 = Slept, ate, or spent time in the same household or room as the case
Contact Sheet Filled by:
Name: ___________________________________ Position: ___________________________ Phone: ________________________
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
2
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
3
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
5
Form Approved
OMB No. 0920‐1011
Exp. Date 03/31/17
Hospitalized Case Investigation Form
Respiratory Illness
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 Reports Clearance Officer; 1600 Clifton
Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
UAC Respiratory Disease Cluster
Hospitalization Case Investigation Form
Alien Number
I. Reporter Information
State/Territory
State/Territory Epi Case ID
State/Territory Lab ID
Date form completed:
/
/
CDC Case ID
Person completing form: First Name:_
Last Name:_
Phone:
What are the source(s) of data for this
Medical chart
Death certificate
Case report form
report? (check all that apply)
Email:_
Other_
II. Patient Information and Medical Care
1. Patient Date of birth:
/
/_
(mm/dd/yyyy)
2. Did the patient have an outpatient or ER
Yes, date:
/_
/
medical care encounter during this illness?
(if multiple, list most recent)
3. Was the patient admitted to the hospital for this
Yes, date:
/_
/
illness?
Time:
:
AM
PM
4. Was patient hospitalized previously at another facility during this illness?
Admission date:
/
/_
Discharge date:
/_
/
6. Height
8. Blood Pressure
11. O Sat
2
Inches
/_
%
9. Respiratory Rate
No
Unknown
Yes
Date taken:
Height
per min
12. Fraction of inspired oxygen
Unknown
No
Unknown
Was discharge from prior hospital a transfer?
Please note initial vital signs at hospital admission/ER presentation.
5. Body Mass
No
/_
/_
Yes
(mm/dd/yyyy)
7. Weight:
Lbs.
Weight Unknown
10. Heart Rate
beats/min Temperature:
13. Using:
O2 mask
room air
ventilator
%
L
°C °F
Specify O2 mask type:
III. Illness Signs and Symptoms
14. Please mark all signs and symptoms experienced or listed in the admission note.
Date of initial symptom onset:
/
/
Fever (measured) highest temp.
°C °F
Date of fever onset
/_
/_
(mm/dd/yyyy)
Feverishness (temperature not measured)
Wheezing
Altered mental status
Cough
Chills
Red or draining eyes (conjunctivitis)
With sputum (i.e., productive)
Headache
Abdominal pain
Hemoptysis or bloody sputum
Excessive crying/fussiness (< 5 years old)
Vomiting
Sore throat
Fatigue/weakness
Diarrhea
Runny nose (rhinorrhea)
Muscle pain/myalgia
Rash, location
Dyspnea/difficulty breathing
Location
Other_
Chest pain
Seizure
IV. Patient Medical History
15. Does the patient have any of the following pre-existing medical conditions? Check all that apply.
15a.
Asthma/Reactive Airway Disease
15h.
Immunocompromising Condition
15b.
Chronic Lung Disease
Emphysema/COPD
Other:_
HIV infection
AIDS or CD4 count < 200
Stem cell transplant (e.g., bone marrow transplant)
Organ transplant
Cancer diagnosis within last 12 months (excluding non-
15c.
Chronic Metabolic Disease
Diabetes
Insulin dependent
Yes
No
Unknown
Other:_
Chemotherapy within last 12 months
Primary immune deficiency
Chronic steroid therapy (within 2 weeks of admission)
Other:
melanoma skin cancer) Type:_
15d.
Blood disorders/Hemoglobinopathy
Sickle cell disease
Splenectomy/Asplenia
Other:_
15i.
Renal Disease
Chronic kidney disease/chronic renal insufficiency
End stage renal disease
Dialysis
Nephrotic syndrome
Other:_
2
No
UAC Respiratory Disease Cluster
Hospitalization Case Investigation Form
Alien Number
15e.
Cardiovascular Disease (excluding hypertension)
Atherosclerotic cardiovascular disease
Cerebral vascular incident/Stroke
Yes
No
Unknown
With disability
Congenital heart disease
Coronary artery disease (CAD)
Heart failure/Congestive heart failure
Other:_
Neuromuscular or Neurologic disorder
15f.
Muscular dystrophy
Multiple sclerosis
Mitochondrial disorder
Myasthenia gravis
Cerebral palsy
Dementia
Severe developmental delay
Plegias/Paralysis
Epilepsy/Seizure disorder
Other:_
15g.
History of Guillain-Barré Syndrome
15j.
Other
Liver disease
Scoliosis
Obese or BMI ≥ 30
Morbidly obese or BMI ≥ 40
Down syndrome
Pregnant, gestational age in weeks:
Post-partum (≤ 6 weeks)
Current smoker
Drug abuse
Alcohol abuse
Other:_
PEDIATRIC CASES ONLY (<18 years old)
Abnormality of upper airway
Yes
No
History of febrile seizures
Yes
No
Premature
Yes
No
(gestational age < 37 weeks at birth for patients < 2yrs)
If yes, specify gestation age at birth in weeks:
Unknown gestational age at birth
Unknown
Unknown
Unknown
Unknown
V. Hematology and Serum Chemistries
16. Were any hematology or serum chemistries performed at hospital
Yes
No (skip to Q. 35)
Unknown (skip to Q. 35)
admission/presentation to care?
Please note initial values at admission/presentation to care. Date values were taken:
/_
/_
(mm/dd/yyyy)
17. White blood cell count (WBC)
cells/mm3 19. Hematocrit (Hct)
% 24. Serum creatinine
mg/dL
18. Differential: Neutrophils
% 20. Platelets (Plt)
103/mm3 25. Serum glucose
mg/dL
Bands
% 21. Sodium (Na)
U/L 26. SGPT/ALT
U/L
Lymphocytes
% 21. Potassium (K)
U/L 27. SGOT/AST
U/L
Eosinophils
% 22. Bicarbonate (HCO3)
mg/dL
U/L 28. Total bilirubin
23. Serum albumin
g/dL 29. C-reactive protein (CRP)
mg/dL
Please describe other significant lab findings (e.g., CSF, protein).
Type of test
Specimen type
Date (mm/dd/yyyy)
Result
31.
/
/
32.
/
/
33.
/
/
34.
/
/
VI. Bacterial Pathogens – Sterile or respiratory site only
35. Was a pneumococcal urinary antigen test performed?
Yes
No
Unknown
If yes, result:
Positive
Negative
Unknown
35. Was a Legionella urinary antigen test performed?
Yes
No
Unknown
If yes, result:
Positive
Negative
Unknown
35. Were any bacterial culture tests performed (regardless of result)?
Yes
No (skip to Q.41)
Unknown (skip to Q.41)
36. . Indicate sites from which specimens
Blood
Cerebrospinal fluid (CSF)
Bronchoalveolar lavage (BAL)
were collected (check all that apply):
Sputum
Pleural fluid
Endotracheal aspirate
Other:_
37. Was there culture confirmation of any bacterial infection?
Yes
No (skip to Q.41)
Unknown (skip to Q.41)
38b. Specimen type:
Blood
Cerebrospinal fluid (CSF)
Bronchoalveolar lavage (BAL)
Sputum
Pleural fluid
Endotracheal aspirate
Other:_
38c. Pathogen(s) identified:
S. aureus
S. pyogenes
S. pneumoniae
H. influenzae
Other:
38d. If Staphylococcus aureus, specify:
Methicillin resistant (MRSA)
Methicillin sensitive (MSSA)
Sensitivity unknown
38a. Positive Culture 1 collection date:
/
/
(mm/dd/yyyy)
39b. Specimen type:
Blood
Cerebrospinal fluid (CSF)
Bronchoalveolar lavage (BAL)
Sputum
Pleural fluid
Endotracheal aspirate
Other:
39c. Pathogen(s) identified:
S. aureus
S. pyogenes
S. pneumoniae
H. influenzae
Other:_
39d. If Staphylococcus aureus, specify:
Methicillin resistant (MRSA)
Methicillin sensitive (MSSA)
Sensitivity unknown
39a. Positive Culture 2 collection date:
/
/
(mm/dd/yyyy)
3
UAC Respiratory Disease Cluster
Hospitalization Case Investigation Form
Alien Number
40b. Specimen type:
Blood
Cerebrospinal fluid (CSF)
Bronchoalveolar lavage (BAL)
Sputum
Pleural fluid
Endotracheal aspirate
Other:_
40c. Pathogen(s) identified:
S. aureus
S. pyogenes
S. pneumoniae
H. influenzae
Other:_
40d. If Staphylococcus aureus, specify:
Methicillin resistant (MRSA)
Methicillin sensitive (MSSA)
Sensitivity unknown
40a. Positive Culture 3 collection date:
/
/
(mm/dd/yyyy)
VII. Respiratory Viral Pathogens
41. Was the patient tested for any other viral pathogens?
Yes
a. Respiratory syncytial virus/RSV
b. Adenovirus
c. Parainfluenza 1
d. Parainfluenza 2
e. Parainfluenza 3
f. Human metapneumovirus
g. Rhinovirus
h. Coronavirus
i. Other, specify:
j. Other, specify:
Positive
Negative
No (skip to Q.42)
Not Tested/Unknown
Unknown (skip to Q.42)
Collection Date
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Specimen Type
VIII. Medications
42. Did the patient receive influenza antiviral medications during illness?
Yes
No
Unknown
Date started
Date stopped
Frequency
Dose
Oseltamivir (Tamiflu)
PO
IV
Inhaled
/
/
/
/
QD
BID
TID
Zanamivir (Relenza)
PO
IV
Inhaled
/
/
/
/
QD
BID
TID
Peramivir
PO
IV
Inhaled
/
/
/
/
QD
BID
TID
Other influenza antiviral:_
PO
IV
Inhaled
/
/
/
/
QD
BID
TID
Other influenza antiviral:_
PO
IV
Inhaled
/
/
/
/
QD
BID
TID
43. Did the patient receive antibiotics during the illness?
Yes
No
Unknown
If yes, name
Date started
Date stopped
Dose
/
/
/
/
PO
IV
IM
/
/
/
/
PO
IV
IM
/
/
/
/
PO
IV
IM
/
/
/
/
PO
IV
IM
/
/
/
/
PO
IV
IM
44. Did the patient receive steroids (excluding inhaled steroids or one time injections) or other
Yes
No
Unknown
immune modulating treatment specifically for this illness?
If yes, name
Date started
Date stopped
Dose
/
/
/
/
PO
IV
IM
/
/
/
/
PO
IV
IM
/
/
/
/
PO
IV
IM
45. Additional treatment comments:
IX. Chest Radiograph – Based on final impression/conclusion of the radiology report
Please include a copy of the radiology report with the form.
46. Did the patient have a chest x-ray within 3 days of
No (skip to Q.52)
Yes, date
/_
/_
admission?
No (skip to Q.52)
Yes, date
/_
/_
47. If yes, was the chest x-ray abnormal?
48. For the abnormal chest x-ray, please transcribe the final impression/conclusion and check all that apply:
Final impression/conclusion:
4
Unknown (skip to Q.52)
Unknown (skip to Q.52)
UAC Respiratory Disease Cluster
Hospitalization Case Investigation Form
Alien Number
Single lobar infiltrate
Multi-lobar infiltrate (unilateral)
Multi-lobar infiltrate (bilateral)
Lobar
or
segmental
collapse
Cavitation/Abscess/Necrosis
Round pneumonia
Alveolar
(air
space)
disease
Interstitial
disease
Mixed (airspace and interstitial) disease
Other Infiltrate:
Bilateral
Pleural Effusion: Unilateral
Complicated
Uncomplicated
Bronchiolitis:
Air leak/Pneumothorax
Lymphadenopathy
Chest wall invasion
Other:
Specify:_
49. Did the patient have another chest x-ray within 3
Yes, date
/_
/_
No (skip to Q.52)
Unknown (skip to Q.52)
days of admission?
50. If yes, was the chest x-ray abnormal?
Yes, date
/_
/_
No (skip to Q.52)
Unknown (skip to Q.52)
51. For the abnormal chest x-ray, please transcribe the final impression/conclusion and check all that apply:
Consolidation:
Final impression/conclusion:
Single lobar infiltrate
Lobar or segmental collapse
Other Infiltrate: Alveolar (air space) disease
Pleural Effusion: Unilateral
Complicated
Bronchiolitis:
Air leak/Pneumothorax
Other:
Specify:_
Consolidation:
Multi-lobar infiltrate (unilateral)
Cavitation/Abscess/Necrosis
Interstitial disease
Bilateral
Uncomplicated
Lymphadenopathy
Multi-lobar infiltrate (bilateral)
Round pneumonia
Mixed (airspace and interstitial) disease
Chest wall invasion
X. Chest CT or MRI – Based on final impression/conclusion of the radiology report
please include a copy of the radiology report with the form.
52. Did the patient have a chest CT/MRI scan within
Yes, date
/_
/_
No (skip to Q.56)
Unknown (skip to Q.56)
3 days of admission?
52. If yes, please select one:
CT: contrast
CT: non-contrast
MRI
54. If yes, was the CT/MRI abnormal?
Yes, date
/_
/_
No (skip to Q.56)
Unknown (skip to Q.56)
55. For abnormal chest CT/ MRI, please check all that apply and please transcribe the final impression/conclusion:
Final impression/conclusion:
Single lobar infiltrate
Lobar or segmental collapse
Other Infiltrate: Alveolar (air space) disease
Pleural Effusion: Unilateral
Complicated
Bronchiolitis:
Air leak/Pneumothorax
Other:
Specify:_
Consolidation:
Multi-lobar infiltrate (unilateral)
Cavitation/Abscess/Necrosis
Interstitial disease
Bilateral
Uncomplicated
Lymphadenopathy
Multi-lobar infiltrate (bilateral)
Round pneumonia
Mixed (airspace and interstitial) disease
Chest wall invasion
XI. Clinical Course and Severity of Illness
56. At any time during the current illness, did the patient require or have the diagnosis of :
a. Admission to intensive care unit (ICU)
Yes
Admission date:
/
/
Discharge date:
If multiple admissions, 2nd ICU admission date:
/
/
2nd ICU discharge date:
If more than 2 ICU admissions, please provide dates in the comments section (Q.66)
Yes
b. Supplemental oxygen
/
Date stopped
Date started:
/
c. Ventilatory support
Yes
Date started:
/
/
Check all that apply:
Intubation
Date stopped:
Date started:
/
/
ECMO
Date stopped:
Date started:
/
/
CPAP
Date stopped:
5
No
/
/
/
/
Unknown
No
/
/
No
/
/
/
/
/
/
Unknown
Unknown
UAC Respiratory Disease Cluster
Hospitalization Case Investigation Form
Alien Number
BiPAP
Date started:
/
d. Vasopressor medications (e.g. dopamine, epinephrine)
Date started:
/
/
e. Dialysis (Acute)
Date started:
/
/
f. Resuscitation, CPR
Yes, date started:
g. Acute respiratory distress syndrome (ARDS)
Yes, date started:
h. Disseminated intravascular coagulopathy (DIC)
Yes, date started:
i. Hemophagocytic syndrome
Yes, date started:
j. Bronchiolitis
Yes, date started:
k. Pneumonia
Yes, date started:
l. Stroke (Acute)
Yes, date started:
m. Sepsis
Yes, date started:
n. Shock
Yes, date started:
Type:
hypovolemic
cardiogenic
septic
toxic
o. Acute myocarditis
Yes, date started:
p. Acute myocardial dysfunction
Yes, date started:
q. Acute myocardial infarction
Yes, date started:
r. Seizures
Yes, date started:
s. Reye’s syndrome
Yes, date started:
t. Acute encephalitis / encephalopathy
Yes, date started:
u. Guillain-Barre syndrome
Yes, date started:
v. Rhabdomyolysis
Yes, date started:
w. Acute liver impairment
Yes, date started:
x. Acute renal failure
Yes, date started:
y. Other, specify:
Yes, date started:
z. Other, specify:
Yes, date started:
/
Date stopped:
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Yes
Date stopped
Yes
Date stopped
stopped:
/_
stopped:
/_
stopped:
/
stopped:
/_
stopped:
/_
stopped:
/_
stopped:
/_
stopped:
/_
stopped:
/_
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
stopped:
stopped:
stopped:
stopped:
stopped:
stopped:
stopped:
stopped:
stopped:
stopped:
stopped:
stopped:
/_
/_
/_
/_
/_
/_
/_
/_
/_
/_
/_
/_
/
Unknown
No
/
/
No
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Unknown
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
XII. Outcomes
Yes, date
57. Did the patient die during this illness?
/_
No (skip to Q.62)
/_
Unknown (skip to Q.62)
58. What was the location of death?
Home
Hospital
ER
Hospice
Other, specify
59. . Did the patient have a DNR (do not resuscitate) order?
Yes
No
Unknown
60. Was an autopsy performed?
Yes (please attach a copy of the autopsy form to this report if available)
No
Unknown
61. What were the causes of death (immediate and underlying) in order of appearance on the death certificate or medical record?
1.
4.
7.
2.
5.
8.
3.
6.
9.
62. Has the patient been discharged from the hospital?
Yes, date
/_
/
No
Unknown
63. If yes, please indicate to where:
Home
Other hospital
Hospice
Rehabilitation Facility
Other long-term care facility
Other, specify:
63. If no, please indicate status:
Hospitalized on ward
Hospitalized in ICU
Died
64. If patient was pregnant, please indicate pregnancy status at discharge or final update:
Still
Uncomplicated labor/delivery
Complicated labor/delivery
pregnant
Describe
64. If pregnancy resulted in delivery, please indicate neonatal outcome: Birth date:
/_
Healthy newborn
Ill newborn, describe:
XIII. Additional Comments
66. Additional Comments:
Fetal loss
/_
Date
6
/_
/
Newborn died: Date
65. Additional notes regarding discharge:
Unknown
/_
/_
Unknown
UAC Respiratory Disease Cluster
Hospitalization Case Investigation Form
Alien Number
7
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Verbal Consent / Assent Script
Hi, my name is _______________. I’m working with the health department and this shelter to find out
what has been making some children here sick with fever and cough. We’d like to ask you some
questions about the symptoms you’ve had in the last week. We will swab your nose and throat to test
for any germs that might be making you sick. You don’t have to answer our questions or allow us to
swab your nose and throat; you can decide if you want to talk to us and let us swab you. We can answer
any questions that you have about the study and procedures. Do you have any questions?
May I ask you some questions now?
□ Yes
□ No
(Complete questionnaire)
May I swab your nose and throat now?
□ Yes
□ No
Place sticker with Alien number here,
DO NOT PUT CHILD’s NAME ON THIS FORM
Verbal consent obtained by: ___________________________________ Date: ____________
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 Reports Clearance Officer;
1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Consentimiento Verbal
El párrafo a continuación se leerá al entrevistado y las respuestas serán registradas por el
entrevistador:
Hola, me llamo_______________, estoy trabajando con el departamento de salud y este
refugio para tratar de entender por qué algunos niños de éste refugio se están enfermando con
fiebre y con tos. Nos gustaría hacerte algunas preguntas sobre los síntomas que has tenido la
semana pasada. Vamos a pasarte un hisopo por la nariz y por la garganta para detectar
algunos gérmenes que podrían estar enfermándote. No tienes que responder a nuestras
preguntas o dejarte pasar el hisopo si no quieres; o si quieres podemos hacerte las preguntas y
pasar un hisopo por la nariz y garganta. Podemos responder a cualquier pregunta que tengas
sobre este estudio y los procedimientos. Tienes alguna pregunta?
¿Puedo hacerte algunas preguntas ahora? □ Sí □ No
(Cuestionario completo)
¿Puedo pasar el hisopo por la nariz y garganta ahora? □ Sí □ No
Place sticker with Alien number here,
DO NOT PUT CHILD’s NAME ON THIS FORM
El consentimiento verbal fue obtenido por: ________________________Fecha: ________
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 Reports Clearance Officer;
1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
| File Type | application/pdf |
| File Modified | 2014-10-27 |
| File Created | 2014-10-27 |