Inventory of ICs - Y1Q4

Appendix 2. Data Collection Forms.pdf

Emergency Epidemic Investigation Data Collections - Expedited Reviews

Inventory of ICs - Y1Q4

OMB: 0920-1011

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-1011 can be found here:

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Today’s date: _______/_______/_______
Day
Month Year

DENGUE CASE INVESTIGATION REPORT

CDC Dengue Branch and Puerto Rico Department of Health
1324 Calle Cañada, San Juan, P. R. 00920-3860
Tel. (787) 706-2399, Fax (787) 706-2496
FOR CDC DENGUE BRANCH USE ONLY
Case number

Specimen #

SAN ID

GCODE

Days post onset (DPO) Type

Date Received

Specimen #

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

Days post onset (DPO)

Type

Date Received

_____/_____/_____ S3

_____/_____/_____

_____/_____/_____ S4

_____/_____/_____

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

Middle Name or Initial

Yes

Unk

Mental status changes:

If patient is a minor, name of father or primary caregiver:
Last Name

First Name

Middle Name or Initial

Home (Physical) Address

Yes

Unk

Physician who referred this case

Home address here

Name of Healthcare Provider:
Tel:

Fax:

Email:

Send laboratory results to (mailing address):
City:

Zip code: __ __ __ __ __ - __ __ __ __

Tel:

Other Tel:

Residence is close to:
Work address:

Patient’s Demographic Information

Date of Birth:

Age:

month Sex:

_______/_______/_______ or Age:
Day

Month

years

Who filled out this form?
M

Pregnant: Y

UNK

Name (complete):

Weeks pregnant (gestation):

Year

Modified Variables for AZ investigation

Must have the following information for sample processing
Day

Date of first symptom:

Month

Year

Duration of hospitalization (days)?

_______/_______/_______

Country of birth

Admitted to the ICU?

Date specimen taken:
Serum:

First sample

_______/_______/_______

Second sample

_______/_______/_______

(Acute = first 5 days of illness – check for virus)

Sought care in Mexico?

Unk

Yes

Unk

During the 14 days before onset of illness, did you TRAVEL to other cities or countries?
Yes, another country

_______/_______/_______

Fatal cases (tissue type):_______________________

Duration of ICU admission (days):

(Convalescent = more than 5 days after onset – check for antibodies)

Third sample

Yes

Yes, another city

Unk

WHERE did you TRAVEL? _____________________________________________________________

_______/_______/_______

PLEASE indicate below the signs and symptoms that the patient had at any time during the illness for which they sought care
Yes

Fever in 7 days before visit….……......
Fever during visit..…………………......
Platelets ≤100,000/mm3………..….....

Unk

Evidence of capillary leak

Warning signs

Lowest hematocrit (%) __________________

Persistent vomiting...................................

Highest hematocrit (%) __________________

Abdominal pain/Tenderness…………..

Lowest serum albumin __________________

Mucosal bleeding …………………….....

Lowest serum protein

Lethargy, restlessness……….…………...

__________________

Lowest platelet count: ______________________________

Lowest blood pressure (SBP/DBP)

Any hemorrhagic manifestation

Lowest pulse pressure (systolic - diastolic)

_________

Petechiae………………………..

Lowest white blood cell count (WBC)

_________

Purpura/Ecchymosis…………..

Symptoms

__________/_______

Yes

Unk

Liver enlargement >2cm………………..
Pleural or abdominal effusion………….
Additional symptoms
Diarrhea……………………………...……..

Vomit with blood……………….

Rapid, weak pulse……………...

Cough…………………………………….…

Blood in stool……………………

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)……....................

Bleeding gums………………….
Blood in urine…………………...
Vaginal bleeding………………
Positive urinalysis……………....
(over 5 RBC/hpf or positive for blood)
Tourniquet test

Pos

CDC 56.31 A REV. 06/2009 (Front)

Neg

Not done

Anorexia……………………….....

Yes

Unk

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

SOUTHERN ARIZONA HOUSEHOLD DENGUE INVESTIGATION
Date of visit (MM/DD /YYYY): ____/___/___
Team number: ___

HOUSEHOLD ENROLLMENT FORM
Complete one form for each household.
1. Cluster ID # - Household ID # : __ __ __ - __ __

2. Phone number (Número de Teléfono): ____________________________________
3. Household Latitude: 32o______._________’N

Longitude: 114o______.__________’W

List all individuals who slept in the house last night and sleep in the house regularly in the last 3
months, starting with the head of household.
If there are not enough spaces, please write the additional information below this section.
Individual ID #
A. _____________________________

Age : _____ yrs

□M □ F

__ __ __ - __ __ - __ __

□ Blood

B. _____________________________

Age : _____ yrs

□M □ F

__ __ __ - __ __ - __ __

□ Blood

C. _____________________________

Age : _____ yrs

□M □ F

__ __ __ - __ __ - __ __

□ Blood

D. _____________________________

Age : _____ yrs

□M □ F

__ __ __ - __ __ - __ __

□ Blood

E. _____________________________

Age : _____ yrs

□M □ F

__ __ __ - __ __ - __ __

□ Blood

F. _____________________________

Age : _____ yrs

□M □ F

__ __ __ - __ __ - __ __

□ Blood

G. _____________________________

Age : _____ yrs

□M □ F

__ __ __ - __ __ - __ __

□ Blood

H. _____________________________

Age : _____ yrs

□M □ F

__ __ __ - __ __ - __ __

□ Blood

_____________________________

Age : _____ yrs

□M □ F

__ __ __ - __ __ - __ __

□ Blood

_____________________________

Age : _____ yrs

□M □ F

__ __ __ - __ __ - __ __

□ Blood

K. _____________________________

Age : _____ yrs

□M □ F

__ __ __ - __ __ - __ __

□ Blood

L. _____________________________

Age : _____ yrs

□M □ F

__ __ __ - __ __ - __ __

□ Blood

M. _____________________________

Age : _____ yrs

□M □ F

__ __ __ - __ __ - __ __

□ Blood

*Individual ID refers to the [cluster ID # - household ID # - individual id #] (e.g. 008 – 01 – 05)

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)

□ Mobile home or
trailer/Casa móvil □ RV □ Single Family Dwelling/domicilio de una sola familia □ Duplex or
Four-plex □Apartment/Apartamento □Multi-story Condominium/Condominio de varios
niveles □Temporary shelter/Refugio temporal □Other: ______________________________
4. Describe structure of the home (Describa la estructura de la casa):

5. What is the source of household water supply? De donde obtiene el agua de su casa?

□ Piped/Public -público □ Well/Pozo □Rain water/agua de lluvia
□ Water tank/tanque de agua (Diamond Brooks) □ Unknown/no se
□Other: __________________

6. In the last 3 months do you store water in open containers on your property? En los
últimos 3 meses tiene usted agua almacenada en envases/depositos abiertos dentro de su
propiedad?:

□Yes □ No □ Don’t know

7. Have you had any visitors that have traveled from out of the country, for example Mexico,
in the last three months? En los últimos 3 meses ha tenido usted visitantes de otro país, por
ejemplo de México?

□ Yes □ No □ Unknown

If YES… 7a. Where did they travel from? De que país vinieron?

□ Mexico □ Other country: ________________________

8. Has anyone in your household including visitors had a fever while residing in the house in
the last three months? Alguna persona en su casa ha tenido fiebre en los últimos tres meses?

□ Yes □ No □ Unknown

9. Does your home have window screens? Tiene su casa mosquiteros en las ventanas ?

□ On all windows □ On some windows □ On no windows □ Unknown

10. In the last 3 months do you leave your windows open? En los últimos 3 meses usted deja
sus ventanas abiertas? Note: If windows only rarely or sometimes left open, please check “no.”

□ Yes, At night and during day □ Yes, at night □ Yes, during the day □ No □ Unknown

10b. If yes, how often do you leave your windows open? Si es asi, con que frequencia
deja sus ventanas abiertas?
Note: If different frequency at different time, pick highest frequency. I.e., if day is always and night rarely, check always.

□ Rarely □ Sometimes □ Usually □ Always □ Unknown
11. In the last 3 months what methods do you use to cool your home? En los últimos 3 meses
que metodos usa para enfriar su casa?

□ Swamp cooler(cooler) □AC (window unit or central air) □ Nothing □Unknown

12. In the past 3 months have you seen mosquitos in your home? En los últimos 3 meses ha
visto mosquitos dentro de su casa?

□ Yes □ No □ Unknown

13. In the last 3 months which of the following methods have you used to control mosquitos
in or around your home? En los últimos 3 meses cual de los siguientes metodos ha usado para
controlar mosquitos dentro o alrededor su casa?

□ Sprayed own house □ Professional sprayed house □ Fogging by Health Department
□ Mosquito coils □ Citronella □ None □ Unknown
13. Do you have a septic tank? Tiene fosa septica?

□ Yes □ No □ Unknown
NOTES:

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

SOUTHERN ARIZONA HOUSEHOLD DENGUE INVESTIGATION
IMMATURE MOSQUITO SURVEY FORM
Complete one form for each household.

Date of visit (MM/DD/YYYY): ____/___/_2014_
Team number: ___________

Case Patient ID Number ID #: ______________-_____________

Container
ID

Type of Container

1
2

Bucket
Tire

Water Drum

Plastic container

Aluminum can

Styrofoam

Jar

Flower vase

Septic tank

Animal watering pan

Potted plant

Bird Bath/Fountains

Other artificial
container:
__________________
Tree:
__________________
Toys

Pools

Sewers

18
19

Bamboo
Other – natural
container (specify)
Tarps

Number of containers (indoors)
Wet – water present
Dry
Larvae/pupae Larvae/pupae
absent
present

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)

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

SOUTHERN ARIZONA HOUSEHOLD DENGUE INVESTIGATION

Specimen Label

INDIVIDUAL INTERVIEW FORM
Team number: ___

Language of interview: □ Spanish □ English Other:_________

Complete one form for each consenting individual in the household.

1. Case Patient ID # - Household ID # - Individual #: __ __ __ - __ __ - __ __
2. Your name Nombre: _________________________________________________________
First (given)
Middle
Last
3. How long have you been living in Arizona? Cuánto tiempo ha estado viviendo en Arizona?
_______ years
4. Have you used mosquito repellent in the past three months? Ha usado repelente de
mosquitos en los últimos tres meses?

□ Yes □ No □ Unknown

5. Have you traveled outside of the country, for example to Mexico, in the past three
months? Ha viajado usted fuera del país, por ejemplo a México, en los últimos 3 meses?

□ Yes □ No □ Don’t know

5a. If you have traveled to Mexico, how often do you travel to Mexico? Si ha viajado a
Mexico, con que frecuencia?

□ Daily □

Weekly

□

Monthly

□

Yearly

5b. If case traveled monthly or yearly, fill out box below. If yes, specify when and
where. Start with most recent travel.

Country 1
Country 2
Country 3

Dates of Travel
Fechas del viaje
(e.g. Dec 2012–Jan 2013)

Duration of travel
Duración del viaje
(weeks)

Country 4
Country 5
6. Have you had a fever in the last three months? Ha tenido usted fiebre en los últimos tres
meses?

□ Yes □ No □ Multiple □ Don’t know

Note: If respondent has had multiple fevers in the last 3 months, repeat all of question 6 using
another copy of the survey for each fever episode that is separated by at least 1 week.
6a. First day of fever. Primer dia con fiebre (MM/DD/YYYY) ______/_______/_______
6b. Did you seek medical attention (e.g. doctor, pharmacist, healer, etc.)? Buscó usted
atención médica (doctor, farmaceutico, curandero, etc.)?

□ Yes □ No □Unknown

6b-1. If yes, what is the name of the health care facility where you sought care?
Si busco ayuda médica, cual es el nombre del lugar?

□ Yuma Regional Medical Center □ Sunset Community Health Center
□ Private physician □ Urgent care □ Mexico □ Unknown
□ Other __________________________

6b-2. If yes, were you diagnosed with Dengue? Si es asi, le han diagnosticado
con Dengue?

□ Yes □ No

6b-3. Were you hospitalized for this illness? Estuvo usted hospitalizado por
esta enfermedad?

□ Yes □ No □ Unknown

6b-4a. Duration of hospitalization. Duración de la hospitalización
________ days
6b-4b. Hospital Name. Nombre del hospital
____________________________________

6c. During your illness, did you have any of the following:
Headache /Dolor de la cabeza
Body/muscle pain /Dolor del cuerpo o los
musculos
Eye pain/ Dolor de los ojos
Rash /Erupcion de la piel
Weakness /Cansancio
Lack of Appetite / Falta de appetito
Nausea/vomiting /Nausea/vomito
Dizziness / Mareos
Severe persistent abdominal pain /Dolor
abdominal severo y persistente
Persistent vomiting (≥3 times in 1 day) /
Vómito persistente
Bruising / Moretones
Nose Bleeding / Sangrado nasal
Bleeding from gums /Sangrado en las
encías
Blood in vomitus / Vomito con sangre
Blood in urine / Sangre en la orina
Blood in stool / Sangre en el excremento
Black, tarry stools / Excreta negra
Heavy vaginal bleeding / Sangrado
vaginal excesivo

Yes

Unknown

7. How do you pay for medical care? Como paga por su cuidado medico?

Comments

□Travel to Mexico and pay out of pocket □Travel to Mexico and use employer insurance □AHCCCS
□VA/Military/TriCare □Employer/private insurance □Don’t access medical care □Other__________
Comments:

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

Dengue Household Investigation in Arizona — Consent Form

The Arizona Department of Health Services and the U.S. Centers for Disease Control and Prevention
(CDC) are investigating an illness called “dengue” that is spread by mosquitoes. There have been several
cases of dengue in your community. We are trying to find out if the virus that causes dengue has been
circulating locally. We are asking volunteer adults and children to answer a short survey and to have
their blood drawn by a doctor or nurse and tested to see if they have had dengue. This investigation will
help us learn what steps we need to take to prevent more dengue cases in your community.
If you agree, we will draw a small amount of blood – about 2 teaspoons – through a needle in your arm.
We will test your blood to see if you have been exposed to dengue, and to see if you currently have
dengue virus in your blood. We will tell you your test results in about a month. The blood draw may
hurt a little. Some people may have bruising or bleeding at the needle site; some people feel dizzy when
they have their blood drawn.
We will ask you to answer a brief survey. The survey will include questions about your health and recent
activities, and about your household.
We will give you information about dengue, including tips for how to avoid dengue. Tips include avoiding
mosquito bites by using mosquito repellent and wearing long sleeved shirts and pants, and emptying or
covering water containers where mosquitoes breed. Also, if you have an illness that you think may be
dengue, you should seek medical care immediately.
Taking part in this survey is voluntary.
If you choose to take part, you may stop at any time. We will keep your information private, to the
extent allowed by law. There is no cost to you for taking part in this survey.
We are happy to answer any questions or concerns about the investigation. You may also contact the
Yuma County Department of Health. Their phone number is 928-317-4550. We will give you a copy of
this form to keep for your records.
Your blood sample will be sent to the CDC for testing. If any blood is left over after the tests are done,
the CDC would like to store the remaining sample, if you agree. Stored samples may be used for future
testing related to dengue or other similar illnesses, or for public health investigations that are relevant
to your community.
□ Yes □ No I agree to allow my blood specimen to be stored at the Centers for Disease Control
and Prevention Dengue Branch.
Your signature:_________________________________

Date______________________

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).

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

Investigación de dengue en hogares de Arizona- Forma de consentimiento

El Departamento de Servicios de Salud de Arizona y los Centros de Control y Prevención de Enfermedades (CDC) están
investigando una enfermedad llamada dengue, que se transmite por mosquitos. Han habido varios casos de dengue en su
comunidad. Estamos intentando investigar si el virus que causa dengue ha estado circulando localmente. Estamos
pidiendo a voluntarios (adultos y niños) responder una breve encuesta y darnos una muestra de sangre tomada por un
médico o enfermero/a. Es una prueba para ver si han tenido dengue. Esta investigación nos ayudará a decidir que acciones
son necesarias para prevenir más casos de dengue en su comunidad.
Si está de acuerdo, tomaremos una pequeña muestra de sangre – unas dos cucharillas- de su brazo con una jeringa. Vamos
a examinar la sangre para ver si usted ha sido expuesto/a a dengue, y para ver si usted en este momento tiene el virus del
dengue en su sangre. Le comunicaremos los resultados de la prueba en un mes aproximadamente. El sacar de la sangre
puede dolerle un poco. A algunas personas les puede causar moretones o salir un poco de sangre en el lugar del pinchazo;
algunas personas pueden marearse cuando se les saque sangre.

Le pediremos que responda a una encuesta breve. La encuesta incluye preguntas sobre su salud, y actividades recientes y
sobre su hogar. Le entregaremos información sobre dengue incluyendo sugerencias de como evitar la enfermedad. Las
sugerencias incluyen evitar la picadura del mosquito usando repelente para mosquitos, llevar camisas de manga larga y
pantalones, y vaciar o cubrir contenedores de agua donde los mosquitos se reproducen. También, si tiene una enfermedad
que crea pueda ser dengue, le recomendamos buscar atención medica inmediatamente.

La participación en esta encuesta es voluntaria. Si decide participar, usted puede dejar de contestar en cualquier momento.
Toda la información la mantendremos privada hasta el punto permitido por la ley. Participar en esta encuesta no tiene
ningún costa para usted.

Estamos a su disposición para responder a cualquier pregunta o preocupación que tenga sobre esta investigación.
También puede contactar al Departamento de Servicios de Salud del condado de Yuma. Su numero de teléfono es 928-3174550. Le entregaremos una copia de este documento para que usted la guarde.
Su muestra de sangre será enviada al CDC para las pruebas. La muestra puede no usarse completamente y de ser así, el
CDC quisiera almacenarla, si usted esta de acuerdo. Las muestras de sangre almacenadas podrían usarse para otras
pruebas en el futuro relacionados con dengue u otras enfermedades similares, o para investigaciones de salud publica
importante para su comunidad. No se harán pruebas de las muestras para condiciones genéticas o para evidencia de
infección con VIH.
☐ Si ☐ No
Estoy de acuerdo en permitir que mi muestra de sangre sea almacenada en la Subdivisión de
Dengue de los Centros de Prevención y Control de Enfermedades (CDC).

Firma: ____________________________________

Fecha ____________________________

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

Dengue Household Investigation in Arizona —Children Assent Form

You may have heard of the dengue virus. We are doing an investigation to find out if people living in
this neighborhood have had this infection, which comes from mosquito bites. We would like you to be
in this investigation. You don’t have to be in the investigation unless you want to. It is up to you.
What will happen?
If you let us, we will take a small amount of blood from you by putting a needle in your arm for a few
seconds. First we will rub your skin with alcohol to clean it.
Will it hurt?
The needle stick in your skin may hurt a little for a few seconds.
Why are we doing this investigation?
This blood test is being done for this investigation. It is not necessary for you. We are not doing it
because you are sick. It will tell us if you had dengue virus in your blood. We will tell you and your
parents what we find out.
You can say, ‘No’
You can say, ‘No’ and we won’t do the blood test. You will not be in trouble if you say, ‘No.’ Would you
like to participate?

Parental permission
If you agree allow your child to participate in this investigation, please check on of the boxes below
regarding storage of your blood specimen, and sign or make your mark below:
□ Yes □ No I agree to allow my blood specimen to be stored at the Centers for Disease Control and
Prevention Dengue Branch.
Your signature:_____________________________

Date _______________________

Investigación de dengue en hogares de Arizona-

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

Forma de consentimiento para niños
Puede que hayas escuchado sobre el virus del dengue. Estamos haciendo una investigación para averiguar
si personas que viven en este barrio han tenido esta infección, causada por la picadura de mosquitos.
Quisiéramos que participaras en esta investigación. No estás obligado a participar si no quieres. Es tu
decisión.
¿Qué va a pasar?
Si nos lo permite, te vamos a sacar una muestra de sangre pinchándote con una aguja en tu brazo por unos
segundos. Primero, vamos a frotarte la piel con alcohol para limpiarla.
¿Me va a doler?
El pinchazo de la aguja en tu piel puede dolerte un poco por unos segundos.

¿Por qué estamos haciendo esta investigación?

No la estamos haciendo porque estés enfermo, estamos haciendo esta prueba solo para esta investigación,
no porque la necesites. La prueba nos dirá si tú has tenido el virus de dengue. Te diremos los resultados a ti
y a tus padres.
Tu puedes decir ‘NO’

Tu puedes decir ‘no’ y no te va a causar ningún problema. Quisieras participar?
________________________________________________________________________

Permiso de tus padres

Si está de acuerdo en permitir que su hijo participe en esta investigación. Por favor, firme y marque una de
las opciones.
☐Si ☐No Estoy de acuerdo en permitir que la muestra de sangre de mi hijo se almacene en la
Subdivisión de Dengue de los Centros de Control y Prevención de Enfermedades.
Firma: _____________________________________ Fecha: ______________________

Form Approved
OMB#0929-1011
expires 03/31/2017

Infection Prevention and Control Questions for Investigation of Mucormycosis Outbreak in BMT Unit
Undergoing Construction
EXISTING PRECAUTIONS
-What special precautions were taken for the construction period?
-all patients in unit 41 and unit 42
-Bone marrow transplant patients
-neutropenic patients?
-immunocompromised patients?
-What barriers or protection from rest of hospital exist (i.e. anteroom or waiting area separating BMT unit)?
-What precautions were taken when patients walk in the hallways? What precautions were taken when patients left the
ward?

POTENTIAL EXPOSURES
-Have you noticed any water damage, leaks, discoloration, moisture/condensation?
-What equipment or supplies are used in the nose or mouths of patients? Where and how are they stored?
(i.e. nasal sprays, nasal cannula, masks, nebulizer machines, medicine/water for breathing tx)
-Are any oral procedures done on the ward?
-Where are linens laundered and stored? How are they delivered to the wards?
-How are the units cleaned?
-How are respiratory viral panels obtained?
-How are patients transported off the units?

AIR SUPPLY
-What is the difference in air quality of rooms on the ward?
-What regular maintenance or upgraded precautions were done on the air supply (HEPA filters/air units)?
-Was ward duct system/plumbing exposed to construction area? Was HVAC system in construction isolated?
-Was vacuuming or air pressure systems used to protect air quality?
-Any air leaks from the outdoors?
-Was air supply shared between unit 41 and unit 42?
-What are the air pressure differentials on unit 41 and unit 42?
-How was air exhausted out of the construction area

CONSTRUCTION
-What other special precautions taken during construction?
-Was construction site completely isolated from ward?
-What kind of barriers were used to isolation construction area?
-What holes existed in completely isolating construction?
-Did any construction personnel have to access ward? If so, what precautions were used?
-How long after construction were barriers removed? How were barriers and debris removed?
-What cleaning was done after construction?
-What air testing or monitoring was done during construction and before barriers were removed?
-What was the flow of patient and construction traffic during theconstruction period?
-How was negative pressure attained? How was it monitored?
-How was demolition waste removed?
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)

[Type text]

Patient Investigation #: ________
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Data Abstraction Form (long-version):
Matched-Case Control Investigation of Mucormycosis Disease
among Bone Marrow Transplant Patients
Patient initials: ________
Patient Investigation #: ________
Medical Record #: ____________
Date of Birth:
Phone #:

/
-

Reviewers Initials: ________
Review Date: ________
Confirmed Case of Nosocomial Rhinocerbral or Pulmonary Mucormycosis Infection
Rhinocerebral or pulmonary mucormycosis in a patient with a hematologic malignancy diagnosed by
histopathology or culture between January 1, 2014 – present with an admission to Hospital A for at least 5 days
within the 30 days prior to date of clinical suspicion for mucormycosis defined as initiation of antifungal
medications for treatment of suspected mucormycosis
Clinical suspicion for mucormycosis is defined as initiation of antifungal medications for treatment of suspected
mucormycosis

Definition of histopathological confirmation
Histopathological examination showing hyphae consistent with a mucormycete from needle aspiration or biopsy
specimen

Definition of culture confirmation
Positive culture result for a sample obtained by sterile procedure from normally sterile
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/AT SDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

Patient Investigation #: ________
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Appendix 1: Case Abstraction Form
Section I: Demographic and Admission Data
1.
2.

Date of Birth: ____/____/____
Gender: __________

Race: (select all that apply)
Asian, American

white/Caucasian

black/African-American

Indian/Alaskan

Hawaiian/Pacific Islander

Ethnicity:

Occupation: ________________

City of Residence: ___________________ State of Residence: _____

Date of clinical suspicion for mucormycosis (mm/dd/yy): ____/____/____

Hispanic

non-Hispanic

Not known

Section II: Underlying Medical Conditions and Risk Factors
8.

Underlying Conditions (active within 30 days prior to or at the time of clinical suspicion for mucormycosis)

Diabetes?
a.

Yes

If yes, specify last Hemoglobin A1C level within 30 days prior to mucormycosis

diagnosis ___________mmol/mol or

Unknown

Date of this HgA1C: __/__/____
b.

If yes, did the patient have Diabetic Ketoacidosis (DKA) during stay on unit?

10. Iron Overload?

Yes

If yes, specify level __________μg/dL or

If yes, check underlying disease

Unknown

Hemochromatosis
Frequent Transfusion
Other________________
11. Previous fungal infections?
a.

Candida spp.

Aspergillus

Unknown

Other______________

Mucormycosis

If yes, date of diagnosis (mm/dd/yy): ____/____/____ or
Yes

Histoplasmosis

Unknown

If yes, specify type: __________________________

13. Solid organ transplant (ever)?
a.

If yes, which organism?

12. Solid tumor malignancy?
a.

Yes

If yes, specify type (select all that apply:

Renal

⁯

Liver

⁯

Lung

Heart

Other (specify) _____________
b.

If yes, date of most recent transplant (mm/dd/yy): ____/____/____ or

14. Aplastic anemia?

Yes

Unknown

Patient Investigation #: ________
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
15. Myelodysplastic syndrome (e.g. RA, RARS, RAEB-1, RAEB-2, RCMD, RCMD/RS, 5q syndrome, CMML)?
Yes

16. Hematologic malignancy?
a.

Yes ⁯

If yes, check all that apply:
Leukemia (if marked, indicate subtype below)
Acute myeloid leukemia (AML) (e.g. M0-M7)
Chronic myeloid leukemia (CML) (e.g. Chronic phase, Accelerated phase, Blast crisis)
Acute lymphocytic leukemia (ALL) (e.g. L1-L3)
Chronic lymphocytic leukemia (CLL) (e.g. B cell origin, T cell origin, Adult T cell leukemia,
Sezary syndrome, Unclassified)
Other___________________
Unknown
Hodgkin’s disease (e.g. Lymphocyte predominant, Lymphocyte rich, Nodular sclerosis, Hairy cell

leukemia, Mixed cellularity, Lymphocyte depleted, Large, granular lymphocyte leukemia)
Non-Hodgkin’s lymphoma (e.g. B cell origin, T cell origin)
Multiple myeloma
Other _______________________________________________
None

Transplant-related history
17. Has the patient had a hematopoietic stem cell transplant?
a.

Yes

If yes, check the type of transplant:
Allogeneic
If allogeneic, which type:

Identical Sib

Haploidentical

MUD

Cord blood

Autologous
b.

If transplant recipient, date of most recent transplant (mm/dd/yy): ____/____/____

If transplant recipient, last CD4count within 30 days prior clinical suspicion for mucormycosis
________cells/mm3 or

Unknown

18. Has the patient had Graft-versus-host disease (GVHD):
a.

If yes, did they have acute GVHD?

Yes

No
No

If yes, record grade (I-IV) __________ or

ii.

If yes, date of most recent acute GVHD diagnosis (mm/dd/yy): ____/____/____ or

Unknown

Unknown
iii.
b.

If yes, is disease:

If yes, did they have chronic
i.

If yes, check one:

Treated

Untreated

Yes

limited

extensive

Unknown

unknown
3

Patient Investigation #: ________
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
ii.

If yes, date of most recent chronic GVHD diagnosis (mm/dd/yy): ____/____/___ or
Unknown

iii.

If yes, is disease:

Treated

Untreated

Unknown

19. Has the patient undergone chemotherapy in the past 30 days prior to clinical suspicion for mucormycosis (If yes,
document chemotherapy agents in the Medication section)
20. Has the patient had neutropenia (< 500 neutrophils per
mucormycosis ?
a.

Yes

mm3 )

Yes

within 30 days prior clinical suspicion for

If yes, total number of neutropenic days within 30 day period: ___________or

Unknown

21. Has the patient received systemic corticosteroids at avg dose ≥0.3 mg/kg/day prednisone (or equivalent) for > 2
weeks?

Yes

Section III: Patient flow
22. Dates of admission during which mucormycosis was diagnosed? (mm/dd/yy): ____/____/____ - ___/___/_____
or

Ongoing, patient is still hospitalized

23. Where was patient admitted from?
Home
Nursing home/subacute care facility
Other acute care hospital
Unknown
a.

If Nursing home, subacute care facility or acute care facility: specify facility name_____________________

24. Did this patient have any inpatient hospitalizations at Kansas University Medical Center within 30 days prior to
clinical suspicion for mucormycosis? Note: include the admission during which the diagnosis was made.
No

Unknown

Yes (fill out the patient flow table below with room locations for all KUMC admissions within 30 days prior to
clinical suspicion and including the admission during which the diagnosis was made. Please choose one location
per row. If a patient moved rooms or units during a single admission, document that change in location on a
separate line, using the same admission number. If a patient had exposure to the same location on a separate
admission, please document this in a separate row with a new admission number. The earliest admission within 30
days of clinical suspicion should be denoted as admission #1) )

Admission #

Unit 41

Location

Room

Start and

Stop date

Unit

Number

(mm/dd/yy)

Unit 42

Unit 45

____/____/____

____/____/____ or
Ongoing

Other, specify_________

Patient Investigation #: ________
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Unit 41

____/____/____

Unit 42

____/____/____ or

Unit 45

Ongoing

Other, specify_________
Unit 41

____/____/____

Unit 42

____/____/____ or

Unit 45

Ongoing

Other, specify_________

Section IV: Medications and Procedures
Medications
25. Has patient received immunosuppressive medications (including chemotherapy and GVHD treatment) within 30
days of clinical suspicion for mucormycosis?
a.

Yes

If yes, please complete the following table:

Immunosuppressant medications

Medication

Most recent dose

Total

Average daily

Indication

prior to clinical

treatment

dose

suspicion

days

(steroids only)

(mm/dd/yy)
MEC

Flu/Cyt/TBI

Induction chemo

FLAG

Intrathecal MTX

Maintenance chemo

Cyt/Daun

Intrathecal Cyt

GVHD

Solumedrol

Prednisone

Other____________

Dexamethasone

None

____/____/____
Unknown

Other___________
MEC

Flu/Cyt/TBI

Induction chemo

FLAG

Intrathecal MTX

Maintenance chemo

Cyt/Daun

Intrathecal Cyt

GVHD

Solumedrol

Prednisone

Other____________

Dexamethasone

None

____/____/____
Unknown

Other___________
MEC

Flu/Cyt/TBI

Induction chemo

FLAG

Intrathecal MTX

Maintenance chemo

Cyt/Daun

Intrathecal Cyt

GVHD

Solumedrol

Prednisone

Other____________

Dexamethasone

None

____/____/____
Unknown

Other___________
5

Patient Investigation #: ________
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
MEC

Flu/Cyt/TBI

Induction chemo

FLAG

Intrathecal MTX

Maintenance chemo

Cyt/Daun

Intrathecal Cyt

GVHD

Solumedrol

Prednisone

Other____________

Dexamethasone

None

____/____/____
Unknown

Other___________
MEC

Flu/Cyt/TBI

Induction chemo

FLAG

Intrathecal MTX

Maintenance chemo

Cyt/Daun

Intrathecal Cyt

GVHD

Solumedrol

Prednisone

Other____________

Dexamethasone

None

____/____/____
Unknown

Other___________
MEC

Flu/Cyt/TBI

Induction chemo

FLAG

Intrathecal MTX

Maintenance chemo

Cyt/Daun

Intrathecal Cyt

GVHD

Solumedrol

Prednisone

Other____________

Dexamethasone

None

____/____/____
Unknown

Other___________

26. Did the patient receive systemic antifungal medication in the 30 days prior to clinical suspicion for mucormycosis
that were given for reasons other than treatment of the mucormycosis infection (i.e. prophylaxis or treatment of
another fungal infection)? DO NOT include drugs given to treat mucormycosis.

Yes (fill out the table below, select one antifungal drug per row)

Antifungal drug

Amphotericin B

Fluconazole

Purpose

Prophylaxis

Micafungin
Posaconazole

Unknown

Start date
(mm/dd/yy)

Stop date
(mm/dd/yy)

Start: ____/____/____

Stop:____/____/____

Unknown
Itraconazole

Unknown

Treatment

Course
Status at time of
diagnosis
Completed
Ongoing
Unknown

Voriconazole
Amphotericin B

Fluconazole

Prophylaxis

Micafungin
Posaconazole

Start: ____/____/____
Unknown

Itraconazole

Treatment

Stop:____/____/____
Unknown

Completed
Ongoing
Unknown

Voriconazole
6

Patient Investigation #: ________
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Amphotericin B

Fluconazole

Prophylaxis

Micafungin

Start: ____/____/____
Unknown

Posaconazole

Itraconazole

Stop:____/____/____

Completed
Ongoing

Unknown

Treatment

Unknown

Voriconazole
Amphotericin B

Fluconazole

Prophylaxis

Micafungin

Start: ____/____/____
Unknown

Posaconazole

Itraconazole

Stop:____/____/____

Completed
Ongoing

Unknown

Treatment

Voriconazole
27. Did the patient have administration of any of the following products to the oral or nasal cavities in the thirty days
prior to diagnosis? (Check all that apply)
Nasal Packing

nasal saline spray

Afrin

RVP

Other_________________

None

28. Did the patient have any inpatient respiratory therapies in the 30 days prior to clinical suspicion for
mucormycosis?
Yes
a.

Unknown

If yes, check all that apply:
NC O2

NC O2 w/ humidified air

CPAP/BIPAP
b.

Other ____________

⁯

Nebulized meds (SVN)
None

MDIs

⁯

Unknown

If ‘yes’ to SVN or MDI, fill in the table below:

Drug

Mode of Administration (SVN or MDI)

Procedures
29. Did the patient have any procedures within 30 days prior to the clinical suspicion for mucormycosis?
No

Unknown

Yes (fill out the patient table below with all procedures within 30 days prior to clinical suspicion and including the
admission during which the diagnosis was made. Please choose one procedure per row. If a patient had the same
procedure on multiple occasions, please document each procedure on a separate row. )

Patient Investigation #: ________
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Procedure

Procedure type

Date (mm/dd/ yy)

Location/Unit

(document for

Procedure

If surgery or

Room

procedure,

OMFS/Dental,

list orifices

ENT,

manipulated

radiology and
GI procedures
Oral Intubation

ICU

Nasal Intubation

Ward

Oral Maxillary

Radiology

____/____/____

Facial/Dental

GI suite

ENT procedure

Unknown

Tracheostomy

Other_________

Bronchoscopy
Radiology
GI procedure
Other________
Oral Intubation

ICU

Nasal Intubation

Ward

Oral Maxillary

Radiology

____/____/____

Facial/Dental

GI suite

ENT procedure

Unknown

Tracheostomy

Other_________

Bronchoscopy
Radiology
GI procedure
Other________
Oral Intubation

ICU

Nasal Intubation

Ward

Oral Maxillary

Radiology

Facial/Dental

____/____/____

GI suite

ENT procedure

Unknown

Tracheostomy

Other_________

Bronchoscopy
Radiology
GI procedure
Other________
8

Patient Investigation #: ________
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Oral Intubation

ICU

Nasal Intubation

Ward

Oral Maxillary

Radiology

____/____/____

Facial/Dental

GI suite

ENT procedure

Unknown

Tracheostomy

Other_________

Bronchoscopy
Radiology
GI procedure
Other________
Oral Intubation

ICU

Nasal Intubation

Ward

Oral Maxillary

Radiology

Facial/Dental

GI suite

ENT procedure

Unknown

Tracheostomy

Other_________

Bronchoscopy
Radiology
GI procedure
Other________
Oral Intubation

ICU

Nasal Intubation

Ward

Oral Maxillary

Radiology

Facial/Dental

GI suite

ENT procedure

Unknown

Tracheostomy

Other_________

Bronchoscopy
Radiology
GI procedure
Other________

Section V: Diagnosis
Radiology
30. Did the patient have a CT head or sinuses within 30 days of clinical suspicion for mucormycosis?
Yes
a.

Unknown

If yes, please list date of first CT head or sinuses after clinical suspicion of mucormycosis: ____/____/____
and findings
9

Patient Investigation #: ________
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Thrombosis

Changes to the orbit

Infarct

Sinusitis

Osteomyelitis

Other findings: ____________________________________________________________
31. Did the patient have a MRI brain within 30 days of clinical suspicion for mucormycosis?
Yes
a.

Unknown

If yes, please list date of first MRI brain after clinical suspicion of mucormycosis : ____/____/____ and
findings
Thrombosis
Changes to the orbit
Infarct
Sinusitis
Osteomyelitis
Other findings: ___________________________________________________________________

Laboratory
Histopatholog y
32. Did patient have specimens sent to pathology for review within 30 days before or 30 days after clinical suspicion
for mucormycosis?
a.

Yes

Unknown

If yes, please complete table:

Date (mm/dd/ yy)

Anatomical site

Mucormycosis

Pathology Technique

mentioned in report
____/____/____

Nasal cavity

Palate

Yes

Morphology

Orbit

Lung

Stain

Skin

Brain

Unknown

Other__________

Other_____________

Other_________
Unknown
____/____/____

Nasal cavity

Palate

Yes

Morphology

Orbit

Lung

Stain

Skin

Brain

Unknown

Other__________

Other_____________

Other_________
Unknown
____/____/____

____/____/____

Nasal cavity

Palate

Yes

Morphology

Orbit

Lung

Stain

Skin

Brain

Unknown

Other_________
Unknown
Nasal cavity
Palate

Other__________

Other_____________

Yes

Morphology

Orbit

Lung

Stain

Skin

Brain

Unknown

Other__________

Other_____________

Other_________
Unknown

Culture
33. Did patient have tissue or aspirate specimens sent for fungal culture within 30 days before or 30 days after clinical
suspicion for mucormycosis?

Yes

Unknown
10

Patient Investigation #: ________
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
a.

If yes, please complete table (do not include blood cultures) :

Culture Date

Specimen Type

Result

Micro Technique

Tissue, specify type:

No growth of fungus

Morphology

Growth of fungus,

Thermotolerance

(mm/dd/yy)
____/____/____

______________
Aspirate

specify organism________

Sinus fluid/drainage

Other_____________
Unknown

BAL
Other_____________

____/____/____

Tissue, specify type:
______________
Aspirate

No growth of fungus

Morphology

Growth of fungus,

Thermotolerance

specify organism________

Sinus fluid/drainage

Other_____________
Unknown

BAL
Other_____________

____/____/____

Tissue, specify type:
______________
Aspirate

No growth of fungus

Morphology

Growth of fungus,

Thermotolerance

specify organism________

Sinus fluid/drainage

Other_____________
Unknown

BAL
Other_____________

____/____/____

Tissue, specify type:
______________
Aspirate

No growth of fungus

Morphology

Growth of fungus,

Thermotolerance

specify organism________

Sinus fluid/drainage

Other_____________
Unknown

BAL
Other_____________

Section VI: Treatment
34. Did the patient undergo surgical treatment for mucormycosis?
a.

Yes

Unknown

If yes, complete the following chart of all surgical treatments for mucormycosis within 30 days after clinical
suspicion.

Patient Investigation #: ________
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Date
(mm/dd/yy)
____/____/____

Surgery type

____/____/____
____/____/____
____/____/____
____/____/____

35. Did the patient receive hyperbaric oxygen therapy (HBO)?

Yes

36. Was the patient treated with an antifungal drug for their mucormycosis infection?

Unknown
Yes

Unknown
a.

If yes, complete table:
Antifungal drug

Route

Start dates
(mm/dd/yy)

Amphotericin B

Posaconazole

Other, specify___________
Amphotericin B

Topical administration
Unknown
IV

Posaconazole

Other, specify___________
Amphotericin B

Topical administration
Unknown
IV

Posaconazole

Other, specify___________

Topical administration
Unknown

37. Did the patient receive iron chelator therapy?
a.

If yes, which medication?

Deferasirox

Total
treatme
nt days

Finished

Start:___/___/____
Unknown

Yes

Course
Status

Ongoing
Unknown
Finished

Start:___/___/____
Unknown

Ongoing
Unknown
Finished

Start:___/___/____
Unknown

Ongoing
Unknown

Deferiprone

Unknown
None

Other (specify)_____________

Section VII: Outcomes
38. Was there extension of the disease from the original site observed at surgical diagnosis?
Yes
a.

Unknown

If yes, did disease extend to:
Brain?

Yes

Orbit?

Yes

Sinuses?

Yes

Jaw?

Yes

Other?

Yes

If yes, specify____________
12

Patient Investigation #: ________
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Yes

39. Did the patient suffer any complications?
a.

Unknown

If yes, did patient develop:
Nerve Palsy?

Yes

Vascular Event?

Yes

Enucleation?

Yes

Renal failure from mediations?

Yes

Other?

Yes

If yes, specify_____________

40. Status at discharge:

Alive

Deceased

Unknown

41. Current status:

Alive

Deceased

Unknown

If deceased, date of death: (mm/dd/yy)____/____/____

If deceased, what was the cause of death? Specify_____________ or

Unknown

If deceased, how was cause of death determined?

Death Certificate

Autopsy report

Chart Review

ICD-9

Other_____________

Section VIII: Symptoms/Signs
42. When was the onset of symptoms? (mm/dd/yy)____/____/____ or

Unknown

Please check all symptoms and signs which were documented within 30 days prior to clinical suspicion for
mucormycosis
Constitutional
43. Fever?

Yes

44. Headache?

Unknown

Yes

Unknown

Ophthalmol ogic/Integument
45. Reddish skin over nose?

Yes

Unknown

46. Swollen skin over nose?

Yes

Unknown

47. Proptosis?

Yes

Unknown

Respiratory
48. Nasal congestion?
49. Rhinorrhea?
50. Dilated pupil?

Yes

No
No

Yes

51. Nonreactive pupil?

Unknown
Unknown

No
Yes

Unknown
No

Unknown

52. Necrotic lesions visualized in mouth?

Yes

53. Necrotic lesions visualized within nares?

Yes

54. Edema of the nasal turbinates?

55. Edema of the posterior pharynx?
56. Sputum production?
57. Hemoptysis?

Yes

Yes
No

Yes
Yes
No

Unknown
No

Unknown

Unknown
Unknown

Unknown

Unknown
13

Patient Investigation #: ________
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
58. Epistaxis?

Yes

Unknown

59. Dyspnea?

Yes

Unknown

Neurologic
60. Facial pain?
61. Tinnitus?

Yes
Yes

62. Ptosis of the eyelid?
63. Cranial Nerve deficits?
64. Alerted Mentation?
65. Blindness of the eye?

No
No

Unknown
Unknown

Yes

Yes
Yes
Yes

Unknown
No

No
No

Unknown
Unknown
Unknown

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

Tainted Beverage Investigation
Medical Record Abstraction

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)

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

Tainted Beverage Questionnaire
Follow up Interviews in the Community
Patient ID
First Name, Last Name, Age, M/F
Neighborhood of residence (radio button list)
Have you had other symptoms during the last 4 weeks? (drop down Y/N)
Have you been seen at the first aid clinic or health center because of these symptoms? (dropdown Y/N)
If yes, were you hospitalized? (dropdown Y/N) / Date of hospitalization:
Neurologic symptoms
Checkboxes:
Weakness - Date of onset/Date of resolution
Generalized weakness – Date of onset/Date of resolution
Extremity weakness - Date of onset/Date of resolution
Loss of sensation - Date of onset/Date of resolution
Paresthesias - Date of onset/Date of resolution
Problems with equilibrium - Date of onset/Date of resolution
Headache - Date of onset/Date of resolution
Dizziness - Date of onset/Date of resolution
Visual changes - Date of onset/Date of resolution
Blurry vision - Date of onset/Date of resolution
Double vision - Date of onset/Date of resolution
Loss of peripheral vision - Date of onset/Date of resolution
Hearing loss - Date of onset/Date of resolution
Buzzing in the ears - Date of onset/Date of resolution
Difficulty swallowing - Date of onset/Date of resolution
Memory loss - Date of onset/Date of resolution
GI symptoms
Checkboxes:
Abdominal pain - Date of onset/Date of resolution
Nausea - Date of onset/Date of resolution
Vomiting - Date of onset/Date of resolution
Diarrhea - Date of onset/Date of resolution
Yellow eyes - Date of onset/Date of resolution
Cardiopulmonary
Checkboxes:
Chest pain - Date of onset/Date of resolution
Palpitations - Date of onset/Date of resolution
Difficulty breathing - Date of onset/Date of resolution

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)

General and other symptoms
Checkboxes:
Fever - Date of onset/Date of resolution
Chills - Date of onset/Date of resolution
Leg swelling - Date of onset/Date of resolution
Bruising - Date of onset/Date of resolution
Bleeding - Date of onset/Date of resolution
Decreased urine output - Date of onset/Date of resolution
(ADD) Loss of appetite - Date of onset/Date of resolution
Do you feel that you are completely cured of this disease? (dropdown Y/N)
If no, are these symptoms affecting your activities of daily living?
Notes/other (free text)

Tainted Beverage - Medical Record Abstraction

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

Clinical data of the Health Centers in Chitima and Songa
Patient ID
First Name, Last Name, Age, M/F
Neighborhood of residence (radio button list)
Date of symptom onset, time of symptom onset
Date of hospitalization, hour of hospitalization
Where hospitalized (drop down: Chitima/Songo/Other)
Date of disposition, hour of disposition
Final disposition (drop down: discharged home, transferred, left AMA, died, no information)
Vital Signs #1: Date, hour, pulse, SBP, DBP, RR, temp
Vital Signs #2: Date, hour, pulse, SBP, DBP, RR, temp
Vital Sings #3: Date, hour, pulse, SBP, DBP, RR, temp
Laboratory Data #1: Date, hour, WBC, Hgb, Hct, Plt, PMN%, Lymph%, MXD% (eos/baso/monocytes), Na,
K, Cl, HCO3, Cl, BUN, Cr, Gluc, AST, ALT, TBili, Alk Phos, TP, Alb
Laboratory Data #2: Date, hour, WBC, Hgb, Hct, Plt, PMN%, Lymph%, MXD% (eos/baso/monocytes), Na,
K, Cl, HCO3, Cl, BUN, Cr, Gluc, AST, ALT, TBili, Alk Phos, TP, Alb
Laboratory Data #3: Date, hour, WBC, Hgb, Hct, Plt, PMN%, Lymph%, MXD% (eos/baso/monocytes), Na,
K, Cl, HCO3, Cl, BUN, Cr, Gluc, AST, ALT, TBili, Alk Phos, TP, Alb
Other laboratory data (free text, consider adding malaria testing as a separate entry)
Medical problems (free text):
Home medications (free text):
Symptoms (checkboxes):
Headache, dizziness, paresthesias, weakness, abdominal pain, nausea, vomiting, diarrhea, cough,
breathing difficulties, chest pain, palpitations, fever, agitation, convulsions, tremor, other symptoms (if
yes, which other symptoms)?
Physician exam (checkboxes):
Ataxia, diminished sensation, muscle weakness, diminished reflexes, abdominal tenderness, vomiting,
diarrhea, hematemesis, dyspnea, rhonchi, leg edema, icterus, agitation, coma, convulsions, tremor
Narrative (free text):
Interventions (free text):

Exposure History for Blood Donors
LAST NAME: _________________________________________ FIRST NAME: _________________________
Male DATE OF BIRTH: ____/____/____
Female

SEX:

RACE: 
White
PHONE: (

AGE____

Black
９
ＣＣ
Ｄ
Asian
ＬＣ ETHNICITY:
Other
Hispanic Non-Hispanic

Unknown


) _________ -_______________________

HOME ADDRESS STREET: _________________________________________________________________
CITY:________________________________ STATE:_______________ZIP:_______________

1. What is your occupation (job title)? ______________________________________________________
2. Were you on the inspection tour on January 20-23? _____Yes

_____No

3. Did you work with rhesus macaque IL38 or rhesus macaque1b22?
Husbandry?

_____Yes

_____No

_____Maybe/Unsure*

Clinical Pathology?

_____Yes

_____No

_____Maybe/Unsure

Treatment of sick animal?
Necropsy?

_____Yes

_____No

_____Yes

_____No

Other (specify) ______________________________________________________________________

4. Have you worked in the TNPRC now or in the past? _____Yes

_____No

_____Maybe/Unsure

5. Have you previously worked with Burkholderia pseudomallei?
_____Yes

_____No

_____Maybe/Unsure

If yes, please explain any possibly exposures:

________________________________________________________________________________________________

6. Did you exit the vehicle while inside the facility? _____Yes

_____No

_____Maybe/Unsure

7. Were you in the van driven by Skip Bohm or by Jim Blanchard on day 1 (circle).
8. Did you:
Area

Necropsy Antiroom
Necropsy Suite
Visit sample transfer area
Animal Clinic
Other Areas

8. a.
Look from outside?

8. b.
Enter inside?

8. c.
Did you touch
anything inside?

9. Did you touch any soil or water while on the tour? _____Yes
10. Location/Site?

_____No

_____Maybe/Unsure

11. Do you have any of the following chronic conditions that can increase your risk of disease from
Burkholderia exposure?
Diabetes

_____Yes

_____No

_____Maybe/Unsure

(blood cancers such as leukemia) _____Yes

_____No

_____Maybe/Unsure

Chronic liver or kidney disease
Alcohol abuse

Hematologic malignancy

_____Yes
_____Yes

Neutropenia or neutrophil dysfunction

_____No
_____No

_____Maybe/Unsure

(low white blood cell count)

_____Yes

cystic fibrosis)

_____Yes

_____No

_____Maybe/Unsure

Long-term steroid use

_____Yes

_____No

_____Maybe/Unsure

Chronic lung disease (asthma,
bronchitis, emphysema,

Thalassemia

Other form of immunosuppression

_____Yes

_____No

_____Maybe/Unsure

_____No

_____Maybe/Unsure

12. Have you ever traveled or been deployed during military service to areas where Burkholderia
pseudomallei occurs naturally, including:
Asia: Thailand, Laos, Singapore, Vietnam, Malaysia, Burma, Vietnam, Taiwan, China
Northern Australia
Africa: South Africa, Madagascar
Central, South America and Caribbean
Country

Dates of Visit

Working in Soil or Water

13. What animals do you have in your home or regularly interact with? If possible include species and
numbers.

_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________

Risk Assessment for individuals who may have had contact with
Burkholderia pseudomallei

Name: __________________________________Department: ______________________________
Date completed: ______________Contact phone number: __________________________
Please complete and return to Occupational Health as soon as possible,

PLEASE CHECK ALL APPROPRIATE BOXES:
LOW RISK
☐
Inadvertent opening of a lid of an agar plate growing B. pseudomallei
☐
Inadvertent sniffing of agar plate growing B. pseudomallei
☐
Splash event leading to visible contact of B. pseudomallei
☐
Spillage of small volume of liquid culture within a functioning biologic safety
cabinet
☐
Contamination of intact skin with culture
HIGH RISK
☐
The presence of any predisposing condition without proper PPE (personal
protective equipment) diabetes mellitus; chronic liver or kidney disease;
alcohol abuse; long-term steroid use; hematologic malignancy; neutropenia
or neutrophil dysfunction; chronic lung disease (including cystic fibrosis);
thalassemia; any other form of immunosuppression
☐
Needlestick or other penetrating injury with implement contaminated with
B. pseudomallei
☐
Bite or scratch by experimental animal infected with B. pseudomallei
☐
Splash event leading to contamination of mouth or eyes
☐
Generation of aerosol outside biologic safety cabinet (e.g., sonication,
centrifuge incident)

Acknowledgements:
☐
☐

☐
☐
☐

☐

I do not believe I have any of the above low or high risk factors.
I have had the opportunity to have all of my questions answered by
Occupational Health
I have had the opportunity to have all of my questions answered by the Office
of Environmental Health and Safety
I have had the opportunity to have all of my questions answered by the Office
of Biosafety
I am aware that I can contact Occupational Health at 985.966.6515 or the
infectious disease department at Tulane at 504.988.5263 if I develop any
symptoms of infection.
I would like to request a private counseling session with (circle one/or more)
Biosafety
OEHS
Occupational Health

Employee Signature: ______________________________________

File Type	application/pdf
Author	LWaller
File Modified	2015-04-10
File Created	2015-04-10