Case Investigation

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Appendix 1: CCHF Case Investigation Questionnaire

CCHF Case Investigation Questionnaire

№

Name of examiner Date of filling

_______________________ ___/_____/_______

№ of history record

Hospitalization Y N

Hospital name___________________________________

Date of hospitalization ___/_____/2011

Demographic data

Date of birth Sex

_____/_____/_______ м F

Residence located in:

Rayon:___________ Sub-district:____________

Employed yes no

Occupation ____________________________________________________________________________

Kind of activity __________________________________________________________________________

Risk factors for CCHF (within 2 weeks before developing a fever)

Tick bite Y N

Date of tick bite: _____/_____/______

Livestock activity Y N

Species contacted:________________________________________

Slaughtering livestock Y N

Species contacted:_________________________________________

Butchering/handling raw meat Y N

Type of meat handled(species):_____________________________

Nursing for person with bleeding Y N

Handling ticks with bare hands Y N

Seeking of medical care due to tick bite Y N

Date of seeking of medical care:_____/_____/_______

Medical facility:_______________________________________

Geographic location of tick bite Rayon:________________ Sub-district:_____________________

Number of ticks removed:____

Tick ID # _______ Species:__________________

Clinical data

Date of symptom/illness onset _____/_____/2011 resolved: _____/_____/2011

Fever Y N onset date: _____/_____/2011 resolved: _____/_____/2011

Headache Y N onset date: _____/_____/2011 resolved: _____/_____/2011

Myalgia/muscle ache Y N onset: _____/_____/2011 resolved: _____/_____/2011

Vomiting Y N onset date: _____/_____/2011 resolved: _____/_____/2011

Diarrhea Y N onset date: _____/_____/2011 resolved: _____/_____/2011

Hemorrhagic syndrome Y N

Hemorrhagic rash Y N Date of onset _____/_____/2011 resolved: _____/_____/2011

Rash Location: Head/face Body Arms/Legs

Hemorrhages/bruising Y N Date of onset_____/_____/2011 resolved: _____/_____/2011

Hemorrhage Location: Head/face Body Arms/Legs

Bleeding Y N Date of onset_____/_____/2011 resolved: _____/_____/2011

Bleeding Location: Gastrointestinal Urogenital Nasal Respiratory

Daily body temperature (maximum value) and blood characteristics

Date (dd.mm)	Тemperature °C	Thrombocyte count	White blood cell count	Red blood cell count	Hemoglobin	Alanine Transferase (ALT)	Aspartate Transferase (AST)

(Other symptoms/attributes):________________________________________________________________________

Treatment

Ribavirin Y N

Date of treatment start:____/_____/2011

Date of end of treatment: _____/_____/2011г.

Dosage: ______________________________________________________________________________________________________________________________________________________________________________________________

Mode of administration: Oral Y N Intravenous Y N

Immune plasma Y N

Date of treatment start: _____/_____/2011г.

Date of end of treatment: _____/_____/2011г.

Total volume/units given: ____________________________________________________________

Date of discharge from the hospital: _____/_____/2011г.

Diagnosis: ____________________________________________

Suspect Probable Confirmed Negative

Outcome

survived died unknown

If patient died, date of death: ____/_____/2011

Diagnostic Tests Performed

Blood collection #1

Date of blood collection ___/_____/_______

CCHF diagnostic testing

Tests Result

IgM ELISA positive Negative Uncertain

IgG ELISA positive Negative Uncertain

Antigen ELISA positive Negative Uncertain

PCR positive Negative Uncertain

Other relevant test results:­­­­­­­_______________________________

Blood collection #2

Date of blood collection ___/_____/_______

CCHF diagnostic testing

Tests Result

IgM ELISA positive Negative Uncertain

IgG ELISA positive Negative Uncertain

Antigen ELISA positive Negative Uncertain

PCR positive Negative Uncertain

Other relevant test results:­­­­­­­_______________________________

Blood collection #3

Date of blood collection ___/_____/_______

CCHF diagnostic testing

Tests Result

IgM ELISA positive Negative Uncertain

IgG ELISA positive Negative Uncertain

Antigen ELISA positive Negative Uncertain

PCR positive Negative Uncertain

Other relevant test results:­­­­­­­_______________________________

Tissue Collection

Date of Tissue collection: ___/_____/_______

Tissues sampled: Liver Spleen Blood clot Lymph node other:

CCHF diagnostic testing

Tests Result

Antigen ELISA positive Negative Uncertain

PCR positive Negative Uncertain

Other relevant test results:­­­­­­­_______________________________

Tick testing for CCHF

Date of test: ___/_____/_______

Antigen ELISA positive Negative Uncertain

PCR positive Negative Uncertain

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)