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) |
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(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)
File Type | application/msword |
File Title | MENINGITIST QES |
Author | Computer |
Last Modified By | DKE |
File Modified | 2014-10-03 |
File Created | 2011-06-29 |