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pdfZika Virus Disease Case Investigation Form
Arboviral Diseases Branch
Version 3.1
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
FOR CDC USE ONLY
CDC R-number______________________________
ZIKVID:__________________
CDC staff initial:_____________________________
Date form completed:_____/_____/_____
CDC investigating group:______________________
Reporting Jurisdiction
Jurisdiction (state/territory):________
Agency:_______________________________
Contact Name:___________________________
Contact Phone:_________________________
Contact Position:_________________________
Contact Email:__________________________
Alternate Contact Name:___________________
Alternate Contact Phone:_________________
Demographic Information
State of residence:___________
State patient ID number:_______________________
Patient last name: _____________________
Patient first name: _____________________
Age: ______ Years Months Days
Sex: Male Female
Travel History
Dates of travel: ____________________
Country(s) visited:____________________________________________________________________________
Vaccination History
Previously vaccinated for:
Yellow Fever Japanese Encephalitis Tick-borne Encephalitis
Cases of Special Interest
Please indicate if patient meets any of the following criteria:
Local vector-borne transmission
Yes No
Pregnant
Yes No Unknown
If yes: Current gestational week:_____
Gestational week at illness onset (if applicable): _____
Fetal loss
Yes No
If yes: Gestational week at time of fetal loss:______
Microcephaly
Yes No
Suspect
Guillain-Barre syndrome/acute flaccid paralysis
Yes No
Suspect
Sexual transmission
Yes No
Suspect
Blood/blood product transfusion transmission
Yes No
Suspect
Organ/tissue transplant transmission
Yes No
Suspect
Breastfeeding transmission
Yes No
Suspect
Page 1 of 2
Suspect
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)
February 5, 2016
Zika Virus Disease Case Investigation Form
Arboviral Diseases Branch
Version 3.1
Illness Information
Illness onset date: _____/_____/_____
Fever
Hospitalized
Died
Yes No
If yes: Subjective fever Measured fever (Maximum measured temperature: _____)
Rash
Yes No
If yes: Type:
Maculopapular Petechial
Purpuric Other
Pruritic: Yes No
Distribution:______________________________________________
Arthralgia
Myalgia
Oral ulcers
Conjunctivitis
Vomiting
Hematospermia (for males)
Headache
Diarrhea
Peripheral edema
Specimen Information
Specimen 1 collected: _____/_____/_____
Type: Serum CSF Amniotic fluid Tissue
Saliva Urine Semen
Specimen 2 collected: _____/_____/_____
Type: Serum CSF Amniotic fluid Tissue
Saliva Urine Semen
Specimen 3 collected: _____/_____/_____
Type: Serum CSF Amniotic fluid Tissue
Saliva Urine Semen
Specimen 4 collected: _____/_____/_____
Type: Serum CSF Amniotic fluid Tissue
Saliva Urine Semen
Specimen 5 collected: _____/_____/_____
Type: Serum CSF Amniotic fluid Tissue
Saliva Urine Semen
Specimen 6 collected: _____/_____/_____
Type: Serum CSF Amniotic fluid Tissue
Saliva Urine Semen
Specimen 7 collected: _____/_____/_____
Type: Serum CSF Amniotic fluid Tissue
Saliva Urine Semen
Page 2 of 2
February 5, 2016
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Public reporting burden of this collection of information is estimated to average 60 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
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# 0929-1011
Expires 03/31/2017
Appendix 1: Case Investigation Form
Public reporting burden of this collection of information is estimated to average 75 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 D74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011).
Form Approved
OMB# 0929-1011
Expires 03/31/2017
Elizabethkingia Spp.
Interview Form:
CDCID
This form is intended to interview patients with:
•
Isolates of any Elizabethkingia spp from any body site with PFGE matching outbreak pattern;
AND
•
The specimen was collected on or after November 1, 2015
When initiating an interview, please use the script appropriate to a participant. Please fill out completely, if patient or proxy does not
know the information, then please check ‘unknown’ or note that question was asked and information is not available.
Was consent given:
Yes
No (DO NOT PROCEED)
Contact Information
Patient contact information
(gather at least State and Zip Code, even if proxy was interviewed):
Name:
Address:
City, State, Zip:
Phone: (
)
Name of residence, if applicable (i.e. nursing home, assisted
living)
Proxy contact information (if applicable):
Name:
Relation to patient:
Relative:
Clinician
Other:
Address:
Same as patient
City, State, Zip:
Phone: (
)
Interview Form Version 5.0 (Updated March 30, 2016). Database Version 2.0 (March 14, 2016)
Elizabethkingia Spp.
Interview Form:
Date of interview:
/
/
Zip code of residence:
State Epi ID (state use only):
Interview Information
Date first culture collected:
/
/
(MM/DD/YYYY)
First date of 30-day exposure period (date of culture collection – 30 days):
First date of 7-day exposure period (date of culture collection – 7 days):
Date interview completed:
Interviewer:
/
/
(MM/DD/YYYY)
/
/
/
/
(MM/DD/YYYY)
(MM/DD/YYYY)
Not applicable. Why?
Name:
Affiliation (state health dept. or CDC):
Linelist patient ID
For interviewer use only:
Information on this report was collected through (check all that apply):
Patient/proxy interview (specify:
Record Review
Review of health department notes
Other:
Must be filled BEFORE faxing to DPH:
Does this patient have laboratory-confirmation of Elizabethkingia spp infection?
Yes
)
Medical
No (STOP interview)
Hello, I am (name, affiliation).
Thank you for taking the time to talk to me today. Understanding healthcare and community exposures you had before you got sick with
Elizabethkingia is critical for identifying the source of these illnesses and stopping more people from getting sick. During this interview I will ask you
about your health, healthcare, and activities in the 30 days before you tested positive for Elizabethkingia. This is the period from (first date of
exposure period) to (date of culture collection) [if conducting in person interview, show a calendar]. To answer these questions, it might be helpful
for you to gather information that will help you remember what you did in the month before you became ill, such as an appointment diary, calendar,
statements from healthcare providers, and receipts from restaurants or travel. This is a standardized interview form we are using for all the patients
affected, to see if we can find some things in common that may have led to people becoming sick with this bacteria. We are still not sure the source of
this outbreak. This bacteria is very rare and relatively newly discovered, so there are a lot of things we don’t know about it. What we do know is that
it likes to live in water and when it has infected people in the past that has typically been people who are already sick in the hospital. For that reason
many of these questions will focus on prior healthcare exposures in the month before you became sick. I’ll also be asking about home exposures,
including water and soil exposures. Then we’ll also talk about food exposures.
InstructionstotheInterviewer-IfthecaseisstillonlyPossibleandnotConfirmed,besuretostate:
“The state health department is automatically receiving any samples of this bacteria from hospital labs, and so we have been informed that you grew
this bacteria on (date) from (body location) . We still need to check the DNA fingerprint of the sample we received and see if it matches the
same fingerprint of the other patients in this outbreak, and so we cannot confirm at this time that you are actually a part of the outbreak.
Nevertheless, we are trying to get ahead of things and start contacting anyone we think MIGHT be affected by the outbreak to ask some questions.”
Please remember that all of your responses are confidential. This interview will take up to an hour.
Are you ready to begin?
Patient Provider (Patient interview or Medical Record Review)
1.
2.
Primary care provider name:
Location and phone number of Primary care provider:
Interview Form Version 5.0 (Updated 4/4/2016)
Database Version 3.0 (Updated 4/4/2016)
2
Elizabethkingia Spp.
Interview Form:
Date of interview:
/
/
Zip code of residence:
State Epi ID (state use only):
Demographic Information (Medical Record Review and Patient Interview)
I will start by asking some questions about your background and where you live.
3.
4.
Date of birth:
/
/
(MM/DD/YYYY)
In the time period from (first date of exposure period) to (date of culture collection) did you stay at least one night in an institutional setting?
Yes
No
Unk
a. If yes, select all that apply:
Nursing home or rehabilitation facility
Assisted living facility
Acute care facility
Other, specify:
5.
What is your race: (check all that apply)
White
Asian
American Indian/Alaska Native
Black
Native Hawaiian/Other Pacific Islander
Unk
Unk
What is your ethnicity:
Hispanic or Latino
Not Hispanic or Latino
What is your sex:
Male
Female
Unk
Are you employed
Yes
No
Unk If yes, place of employment, location (city) of employment?
6.
7.
8.
Healthcare Exposure (Patient Interview)
I am now going to ask you about your healthcare exposures that occurred in the 30 days before you became ill, the period from (first date of exposure
period) to (date of culture collection). I will refer to this period as the month before you became ill.
9.
In the month before you became ill, did you receive home health services (including wound checks, dressing changes, baths)?
Unk
Please tell me about each of these home health visits, starting with the most recent.
a. If yes, please list:
Date
Agency Name and Contact Information
Yes
No
Reason for Visit
10. In the month before you became ill, did you have any outpatient visits at a clinic with healthcare providers (this does not include outpatient visits for
dialysis)? Examples of healthcare providers are primary care providers, specialists such as cardiologists or oncologists, eye doctors, and dentists.
Yes
No
Unk
a. If yes, please list your appointments:
Date
Clinic Name (phone number and address, if known)
and Specialty Type
Reason for Visit
11. In the month before you became ill, were you receiving outpatient dialysis?
Yes
No
Unk
a. If yes, what type of dialysis:
Hemodialysis
Peritoneal Dialysis
Unk
b. Name and contact information for dialysis facility:
c. If hemodialysis please specify access type:
fistula
graft
central venous catheter
other
d. What days do you receive dialysis
MWF
T TH S
Other
Unk
e. Last dialysis session before symptoms onset. Date:
do not know
Interview Form Version 5.0 (Updated 4/4/2016)
Database Version 3.0 (Updated 4/4/2016)
Unk
3
Elizabethkingia Spp.
Interview Form:
Date of interview:
/
/
Zip code of residence:
State Epi ID (state use only):
12. In the month before you became ill, did you go to the emergency room for any reason?
a. If yes, please tell us more:
Date
Hospital Name and Contact Information
Yes
No
Unk
How did you get to the
hospital?
Reason for ER Visit
EMS
POV
Other
EMS
POV
Other
EMS
POV
Other
EMS
POV
Other
EMS
POV
Other
13. Have you been to an Urgent Care in the month prior to illness onset?
a. If yes, please tell us more:
Date
Yes
Urgent Care Name and Contact Information
No
Unk
Reason for Urgent Care Visit
14. In the month before you became ill, did you have an overnight stay at a nursing home? This does not include assisted living facilities?
Yes
No
Unk
15. In the month before you became ill, were you hospitalized overnight?
Yes
No
Unk
a. Please tell me all long term care facilities and hospitals where you were a patient overnight in the month before you became ill (including
multiple stays or admissions).
Name and Type of Facility
(nursing home, hospital)
Location (Address and
phone number)
Interview Form Version 5.0 (Updated 4/4/2016)
Indication
Database Version 3.0 (Updated 4/4/2016)
Admission date
(MM/DD/YYYY)
Discharge date
(MM/DD/YYYY)
4
Elizabethkingia Spp.
Interview Form:
Date of interview:
/
/
Zip code of residence:
State Epi ID (state use only):
16. Have you received care from any of the following in the month prior to illness onset?
Yes
No
Unk
Location
Exposure
Were any procedures
beyond a routine
examination performed?
If yes, describe.
Date(s)
(MM/DD/YYYY)
.
Dentist
Podiatrist
Chiropractor
Massage
Therapist
Naturopath
17. In the month before you became ill did you use any of the following medications, check all that apply
a. Inhalers
Yes
No
Unk
b. Nebulizers
Yes
No
Unk
c. Nasal sprays
Yes
No
Unk
d. Eye drops
Yes
No
Unk
e. Oxygen
Yes
No
Unk
f. Over the counter supplements, including vitamins, probiotics, powders added to a drink or smoothie (e.g., protein powder)
Yes
No
Unk
If yes, specify type and brand
g. Thickened juice, food, or shakes?
Yes
No
Unk
®
™
®
i. If yes, which brand of thickener?
Simply Thick
Thick-It ReadyCare 2.0
Hormel Thick & Easy
specify:
Unknown
ii. If yes, specify type of thickener:
Unknown
h. Proton pump inhibitors (PPI). Examples of PPI are Prilosec, Prevacid, and Nexium.
Yes
No
Unk
i. H2 blockers. Examples of H2 blockers are Zantac and Tagamet.
Yes
No
Unk
j. Antibiotics
Yes
No
Unk
i. If yes, check all those that were received:
Amikacin
Amoxicillin
Amoxicillin/Clavulanic Acid
Ampicillin/sulbactam
Azithromycin
Aztreonam
Cefaclor
Cefazolin
Cefdinir
Cefepime
Cefotaxime
Cefpodoxime
Interview Form Version 5.0 (Updated 4/4/2016)
Cefprozil
Ceftazidime
Ceftizoxime
Ceftriaxone
Cefuroxime
Cephalexin
Ciprofloxacin
Clarithromycin
Clindamycin
Colistin
Daptomycin
Doripenem
Doxycycline
Ertapenem
Fosfomycin
Gentamicin
Imipenem
Levofloxacin
Linezolid
Meropenem
Metronidazole
Moxifloxacin
Nitrofurantoin
Ofloxacin
Database Version 3.0 (Updated 4/4/2016)
Othe
Penicillin
Piperacillin-Tazobactam
Polymyxin B
Rifampin
Tetracycline
Ticarcillin/Clavulanic Acid
Tigecycline
Tobramycin
Trimethoprim-Sulfamethoxazole
Vancomycin
Other (specify):
Other (specify):
5
Elizabethkingia Spp.
Interview Form:
Date of interview:
/
/
Zip code of residence:
State Epi ID (state use only):
18. In the month before you became ill, did you experience any of the following:
If Yes, Date of
Symptom Onset
Sign/Symptom
Present
(MM/DD/YYYY)
Write UNK if
unknown
Open wounds,
sores, or skin injury
Yes
No
Unk
(i.e. ulcers, burns,
cuts, or scrapes)
Notes (describe
circumstances)
Treatment (include
description of
products used)
19. In the month before you became ill, did you receive any medication or immunization injections (i.e., intramuscular (IM), subcutaneous (SQ),
intradermal (ID) shot, not through a catheter or during dialysis. Does not include IV infusions)?
Yes
No
Unk
a. If yes, please tell us more:
Medication
Date of last injection?
How frequent are the injections?
20. In the month before you became ill, did you receive any intravenous infusions (infusions into the vein) for saline, medicines, or vitamins?
Yes
No
Unk
a. If yes, please tell us more:
Medication/Vitamin or
Date(s)
Substance (including saline or
Facility or Location (Address/Phone number)
(MM/DD/YYYY)
heparin
21. In the month before you became ill, were any central, peripheral lines or other IV catheters present? (for example, intravenous line, dialysis line not
including a dialysis graft or fistula)
**NOTE FOR INTERVIEWER: THIS LINE COULD HAVE BEEN INSERTED PRIOR TO 30 DAYS, BUT MUST HAVE BEEN PRESENT IN THE MONTH PRIOR
TO ILLNESS.
Unk
Yes
No
a. If yes, please tell us more:
Date of Insertion
(MM/DD/YYYY)
Type of intravenous catheter
Interview Form Version 5.0 (Updated 4/4/2016)
Database Version 3.0 (Updated 4/4/2016)
6
Elizabethkingia Spp.
Interview Form:
Date of interview:
/
/
Zip code of residence:
State Epi ID (state use only):
22. In the month before you became ill, did you have any implanted medical devices (includes any device regardless of time placed)? (joint
replacements, bone plates, cardiac defibrillator/pacer, heart valves, vascular stents, urinary catheter, etc.). Note: This does not include central or
peripheral venous catheters which should be captured above
Yes
No
Unk
a. If yes, please tell us more:
Device Type
Interview Form Version 5.0 (Updated 4/4/2016)
Device Location (note Left/Right if applicable)
Database Version 3.0 (Updated 4/4/2016)
Year Implanted
7
Elizabethkingia Spp.
Interview Form:
Date of interview:
/
/
Zip code of residence:
State Epi ID (state use only):
Home Exposures (Patient Interview)
Thank you for providing that information. Now I am going to ask you questions about potential exposures at home and in the community.
23. How long before you became ill did you live in your current home?
months/years
Unk
24. In the month before you became ill, did you make any changes to your plumbing, heating, or cooling systems?
a. If yes, please explain:
25. In the three months before you became ill, were your plumbing, heating, or cooling systems serviced?
a. If yes, please explain:
26. Describe the water supply used in the month prior to becoming ill?
municipality
)
Other, specify
27. Does your home water use a de-chlorinator
a.
b.
Yes
Yes
Private Well
Unk
No
Yes
No
No
Unk
Unk
City or Municipal water (Specify
Unk
If yes, when was the filter last replaced prior to illness onset?
Type of filter?
Unk
Unk
28. Does your home water use a softener
Yes
No
Unk
29. Where did you get your drinking water in the month before you became ill, check all that apply?
Home Tap
Point of Use Filter
Bottled
Other, specify
30. In the month before you became ill, did you consume commercially bought ice?
a. If yes, specify brand and location:
31. In the month before you became ill, did you use a humidifier in your home?
Yes
Yes
No
No
Unk
Unk
32. In the month before you became ill, did you use a Neti-Pot or performed nasal rinsing?
a.
Unk
Yes
If yes, what is the water source used?
No
Unk
Unk
33. In the month before you became ill, did you have an aquarium in your home?
34. In the month before you became ill, did you have any pets at home?
Yes
No
Yes, specify
35. Did you have any exposure to animals in the 2 weeks before you became ill?
36. Did you have any plants in your home in the month before you became ill?
Unk
No
Yes, specify
Unk
No
Yes, specify
No
Unk
Unk
37. In the month before you became ill, did you have any contact with cut flowers?
Yes
No
Unk
38. In the month before you became ill, did you come in to contact with any soil such as during gardening, farming, sports, or other outdoor activities?
Yes
No
Unk
a. If yes, please describe:
39. How do you bathe, check all that apply?
Bath
Shower
Sponge bath
40. Do you have dentures?
Yes
No
Whirlpool
Other, please specify
Unk
41. What brand of toothpaste did you use in the month before you became ill?
Interview Form Version 5.0 (Updated 4/4/2016)
Unk
Database Version 3.0 (Updated 4/4/2016)
Unk
8
Elizabethkingia Spp.
Interview Form:
Date of interview:
/
/
Zip code of residence:
State Epi ID (state use only):
42. Did you use mouthwash in the month before you became ill?
Yes
No
a. If yes, which brand?
Unk
43. In the month before you became ill, did you use any topical products (e.g., lotions, creams, liniments, or ointments)?
a. If yes: Please tell me all of the products you used during this period.
44. In the month before you became ill, did you use any peri-anal creams, pads, or medications?
Yes
No
a. If yes: Please tell me all of the peri-anal creams, pads or medications you used during this period.
45. In the month before you became ill, did you use any soaps or bodywashes?
Yes
a. If yes: Please tell me all of the soaps and body washes you used during this period.
46. In the month before you became ill, did you use any shampoos?
Yes
a. If yes: Please tell me all of the shampoos you used during this period.
No
No
Yes
No
Unk
Unk
Unk
Unk
47. Where did you purchase the personal care products that you used in the month before you became ill (e.g., soap, shampoo, creams and lotions,
toothpaste, deodorant)? Check all that apply and specify location:
Drug Store
Grocery Store
Name
On-line
Other
Location
48. Now I would like to ask about a topic that might be sensitive to you. Please remember that your responses are confidential.
In the month before you became ill, did you use marijuana, also called cannabis, in any form?
Yes
No
Refuse to answer
Unk
a. If yes, specify route (check all that apply):
Smoked
Ate
Topical (oils)
Other (specify)
49. Do you know of anyone else in your home or community that has experienced a similar illness?
Yes
a. If yes, who:
50. Were you been bitten by any insect in the month before you became ill?
Yes
No
Unk
a. If so which?
51. In the month before you became ill, have any pets in your home had insect infestations (i.e., fleas)?
No
Yes
52. In the month before you became ill, did anyone live (stay overnight) with you in your home?
Yes
No
If yes: Please tell me more about all the people who live with you:
Name
Phone Number
Relationship
Occupation
Place of Employment
Interview Form Version 5.0 (Updated 4/4/2016)
Database Version 3.0 (Updated 4/4/2016)
Unk
No
Unk
Check if surveillance
cultures were obtained
9
Elizabethkingia Spp.
Interview Form:
Date of interview:
/
/
Zip code of residence:
State Epi ID (state use only):
53. In the 7 days before you became ill, did you have any visitors to your home?
If yes: Please tell me more about all the people who visited you:
Name
Phone Number
Relationship
County of
Residence
Yes
No
Unk
Occupation
Place of Employment
Outside Exposure (Patient Interview)
54. In the month before you became ill did you attend any of the following check all that apply:
Exercise gym/group
Club
Social gathering
None
55. If yes to any of the above, please specify when and where
Religious service
Support Group
NotetoInterviewer:Ifyouwillbeconductingthefullfoodexposurequestionnairewiththispatientthenskipquestions56-58andproceedtoquestion
59.
I am now going to ask you some questions about food you have eaten which will focus only on the 7 days before you became ill, which is the period
from (7 days prior to date of culture) to (date of culture collection).
56. In the 7 days before you became ill, where did your food come from that was prepared at home
a. Grocery store
Yes
No
Unk
2.
3.
i. If yes, specify 1.
b. Farmers market/food purchased directly from farm
Yes
No
Unk
i. If yes, specify 1.
2.
3.
c. Health food store
Yes
No
Unk
2.
i. If yes, specify 1.
3.
d. Ethnic specialty market
Yes
No
Unk
i. If yes, specify 1.
2.
3.
e. Fish or meat shop (e.g., butcher’s)
Yes
No
Unk
2.
i. If yes, specify 1.
3.
f. Hunting or fishing
Yes
No
Unk
i. If yes, specify 1.
2.
3.
g. Locally grown fresh foods, e.g., hydroponic greens
Yes
No
Unk
i. If yes, specify 1.
2.
3.
Not applicable (my food is prepared and controlled by my residence facility)
57. In the 7 days before you became ill, did family or friends bring you food from outside the facility?
Yes
No
Unk
If yes, please describe:
58. In 7 days before you became ill, did you eat food prepared outside the home, such as from a restaurant, meal delivery service, or at a school, or
hospital? This includes foods that you ate outside the home, brought home, or had delivered
Yes
No
Unk
a. Restaurants (including deliveries such as pizza)
Yes
No
Unk
i. If yes, specify 1.
2.
3.
b.
Meal delivery service, such as meals on wheels
i. If yes, specify 1.
2.
c.
Institution, such as hospital or school
Yes
i. If yes, specify 1.
2.
Interview Form Version 5.0 (Updated 4/4/2016)
Yes
No
No
Unk_
3.
Unk
3.
Database Version 3.0 (Updated 4/4/2016)
10
Elizabethkingia Spp.
Interview Form:
Date of interview:
/
/
Zip code of residence:
State Epi ID (state use only):
59. In the 7 days before you became ill, did you use any consumables (lotions, balms, salves) prepared outside the U.S.?
60. In the 7 days before you became ill, did you consume any foods from outside the U.S.?
Yes
No
Unk
Yes
No
Unk
Thank you. Now I am going to ask you a few more questions about your activities. These questions will refer to the full 30 day period from (first date
of exposure period) to (date of culture collection).
61. In the month before you became ill, did you do any of the following activities?
Yes
No
Unk
Exposure
Location
Date(s)
(MM/DD/YYYY)
Swimming, hot tub
Water aerobics
Water park
Fishing
Steam room, or
wet sauna
Hot tub or
whirlpool/spa
Other:
62. In the month before you became ill, did you travel anywhere outside your home town, even for part of a day? Please include any towns that you
visited where you ate a meal or bathed, showered, or swam.
Yes
No
Unk
a. If yes, please list the places you visited.
Location
Date(s)
(MM/DD/YYYY)
63. Any additional comments or notes (e.g. travel details, additional visits to healthcare providers, other diagnostic testing, and information)?
Interview Form Version 5.0 (Updated 4/4/2016)
Database Version 3.0 (Updated 4/4/2016)
11
Elizabethkingia Spp.
Interview Form:
Date of interview:
/
/
Zip code of residence:
State Epi ID (state use only):
InterviewerInstructions:Ifyouwillbeconductingthefullfoodexposurequestionnaireproceedtoitatthispoint. Ifyouwillnotbeconductingthefull
foodexposurequestionnairethentheinterviewiscompleted.
This is the end of the interview. Thank you very much for your time and willingness to provide this valuable information.
If you have any questions please feel free to contact Wisconsin Division of Public Health at 608-267-9003.
If necessary, would it be okay to contact you again in the future with any follow-up questions?
Thank you, and take care.
Interviewer: Please fax completed forms to 608-261-4976
Interview Form Version 5.0 (Updated 4/4/2016)
Database Version 3.0 (Updated 4/4/2016)
12
Form Approved
OMB# 0929-1011
Expires 03/31/2017
Appendix 3: Case Series Form
Public reporting burden of this collection of information is estimated to average 60 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).
Patient CDCID:
Wisconsin Clinical Course Abstraction Form
SECTION A
Section A Instructions: Abstract Section A using all medical records relevant to Elizabethkingia infection. This
includes the medical record from the outpatient encounter, ER, or hospitalization where the positive culture was
collected and follow-up care (hospitalization for EK, care at AL for EK, or outpatient treatment for the positive
culture). If a patient was transferred during their EK hospitalization, abstract medical records for EK
hospitalization from both facilities.
Obtain list of ICU locations from hospital prior to abstraction to ensure that all ICU stays are captured in item 21.
Patient CDCID:
Abstractor Name:
Date of Abstraction:
Specify name of facilities included in abstraction for Section A:
1. Age:
2. Sex:
Male
Female
3. Race (check all that apply):
White
Native Hawaiian/Other Pacific Islander
4. Ethnicity:
Unk
Hispanic or Latino
Asian
American Indian/Alaska Native
Black
Unk
Not Hispanic or Latino
Unk
5. County of residence:
6. Date of collection of first specimen positive for E. anophelis:
/
/
(MM/DD/YYYY)
7. Time of collection of first specimen positive for E. anophelis:
(HOURS/MINUTES; 24 HOUR CLOCK)
8. Where was the first specimen positive for E. anophelis collected (select one)?
Inpatient
LTCF/SNF
Emergency Room
LTACH
Observational unit/Clinical Decision Unit
Dialysis clinic
Outpatient
Other (specify):
Assisted Living
Unknown
Patient CDCID:
9. Was patient hospitalized at the time of or during the 7 days after the first specimen positive for E.
anophelis was collected?
Yes
No
Unk
a.
If yes, specify date of admission:
b.
Was patient transported to the hospital by EMS/ambulance (this is only intended to capture
emergency transports by EMS not planned transfers via private ambulance)?
Yes
No
Unk
/
/
(MM/DD/YYYY) (If patient was hospitalized and
transferred, specify first date of admission)
Unk
c. Was patient transferred to a different short stay acute care hospital at any point after the first
specimen positive for E. anophelis was collected?
Yes
No
Unk
If yes, specify date(s) of transfer:
/
/
(MM/DD/YYYY)
d. List all admission diagnoses on H&P:
10. Where was the patient admitted from? (select one)
Private residence
LTCF/SNF
Acute care hospital inpatient
LTACH
Homeless
Other (specify):
Assisted living
Unknown
11. History of present illness at the time of hospital admission (please briefly summarize details from the
H&P):
Patient CDCID:
12. Past Medical History known at time first positive specimen was collected (check all that apply)
None
Unknown
AIDS
Atrial Fibrillation
History of alcohol abuse
Asplenia
Asthma
Autoimmune disease
Cerebrovascular disease/stroke (except hemiplegia)
Cerebral palsy
Chronic cognitive deficit
Chronic kidney disease (not on dialysis)
Chronic kidney disease (on dialysis)
Chronic liver disease without cirrhosis
Cirrhosis
Chronic obstructive pulmonary disease
(COPD)/emphysema
Chronic lung disease (other than COPD/emphysema,
asthma)
Chronic steroid or other immunosuppressive therapy
Chronic ventilation/tracheostomy
Congenital heart disease
Congestive heart failure
Connective tissue disease
Cystic fibrosis
Dementia
Diabetes mellitus with complications
Diabetes mellitus without complications
Eczema
Failure to thrive
Hemiplegia
HIV without AIDS
Inflammatory bowel disease (Ulcerative Colitis/Crohns)
Ischemic heart disease
History of IVDU
Kidney stones/nephrolithiasis
Leukemia
Lymphoma or multiple myeloma
MRSA colonization or infection history (prior to admission)
Myocardial infarction
Neutropenia (absolute neutrophil count <500 cells/µL)
Peptic ulcer disease
Peripheral vascular disease
Postpartum (30 days or less)
Pregnancy (current)
Pulmonary hypertension
Recurrent cystitis or urinary tract infection
Sickle cell disease
Solid
tumor
malignancy,
metastatic
Solid
tumor
malignancy,
not
metastatic
Spinal cord injury or paraplegia or quadriplegia
Transplant, hematopoietic stem cell or bone marrow
Transplant, solid organ
Other
Other
Other
a. Summarize other past history not captured above:
13. Did the patient have any of the following exposures at time of hospital admission?
a. Current smoking:
Yes
No
Unk , if yes, specify pack years:
Unk
b. Current alcohol use:
c. Current illicit drug use:
Yes
Yes
Unk , if yes, specify drinks per week:
No
Unk , if
No
Drug
Frequency
Unk
Drug
Frequency
Unk
Drug
Frequency
Unk
yes, specify drugs and frequency:
Unk
Patient CDCID:
14. Did the patient have any medication allergies? :
Yes
No
Unk
If yes, specify all:
15. Specify all symptoms reported by patient on the date the first positive specimen was collected and the
onset date reported by the patient (if known). Check No only if the records indicate the patient denied
the symptom was present; otherwise specify unknown.
Symptom
If Yes, Date of
Symptom Onset
(MM/DD/YYYY)
Write UNK if
unknown
Symptom Present?
Weakness
Yes
No
Unk
Headache
Yes
No
Unk
Lightheadedness, Dizziness
Yes
No
Unk
Blurry vision
Yes
No
Unk
Yes
No
if yes, temp
Unk
oF
Documented Fever (T >100.3)
Subjective fever
Yes
No
Unk
Night sweats
Yes
No
Unk
Chills
Yes
No
Unk
Cough
Yes
No
Unk
Wheezing
Yes
No
Unk
Sore throat / difficulty swallowing
Yes
No
Unk
Muscle aches
Yes
No
Unk
Chest pain
Yes
No
Unk
Shortness of breath
Yes
No
Unk
Vomiting
Yes
No
Unk
Nausea
Yes
No
Unk
Diarrhea
Yes
No
Unk
Abdominal pain
Yes
No
Unk
Joint pain
Yes
No
Unk
Bleeding gums
Yes
No
Unk
Mouth sores
Skin wound
Yes
Yes
No
No
Unk
Unk
Rashes
Yes
No
Unk
Skin warmth
Skin redness
Yes
Yes
No
No
Unk
Unk
Skin pain
Yes
No
Unk
Altered mental status
Other specify
Yes
Yes
No
No
Unk
Unk
Other specify
Yes
No
Unk
Other specify
Yes
No
Unk
Patient CDCID:
16. Specify all physical exam findings documented by the clinical team on the date the first positive
specimen was collected. Check No only if the records indicate the finding was not present (e.g., if team
documents skin exam was normal then would check No for skin signs); otherwise specify unknown.
Sign
Sign Present?
Altered mental status
Yes
No
Unk
Rash
Skin redness
Yes
Yes
No
No
Unk
Unk
Skin tenderness
Yes
No
Unk
Skin warmth
Yes
Yes
No
No
Unk
Unk
Cellulitis specifically documented
Other specify
Other specify
Yes
No
Unk
Yes
Yes
No
No
Unk
Unk
Other specify
Yes
No
Unk
Other specify
Yes
No
Unk
Other specify
Other specify
Yes
Yes
No
No
Unk
Unk
Other specify
Yes
No
Unk
Skin wound (including decubitus ulcer)
17. Vital signs documented closest to time of collection of first positive specimen
None
Date / /
Time:
Unknown
(MM/DD/YYYY)
Unk
(HOURS/MINUTES; 24 HOUR CLOCK)
Parameter (include units)
Systolic Blood pressure (mmHg)
Diastolic Blood pressure (mmHg)
Pulse (beats per minute)
Respiratory rate (breaths per minute)
Temperature (degrees F)
Pulse Ox (percent)
Unk
Result
Percent saturation
On O2
Yes
No
If Yes, mode of delivery:
Other (specify):
If yes, FiO2:
Unk
Unk
Nasal cannula
or L/Min:
Intubated
(if FiO2 not documented)
Patient CDCID:
18. Record each for the 3 days beginning with the day of collection of first positive specimen. If only 1 value
was documented (e.g., only 1 wbc value recorded for a given day) record the value as both the highest
and the lowest.
Day 1 (Day culture was
performed)
Date:
/
/
Day 2
Date:
/
/
Day 3
Date:
/
/
Highest systolic blood pressure
Lowest systolic blood pressure
Highest heart rate
Lowest heart rate
Highest respiratory rate
Lowest respiratory rate
Highest WBC
Lowest WBC
Highest proportion bands
Altered mental status present
(Yes/No/Unknown)
19. Complete supplementary Table 1. For each day of the patient’s hospital admission, record vitals
documented closest to 6am and 6pm in the medical record. If the patient was already hospitalized at
the time their first positive specimen was collected, document vitals starting 7 days prior to specimen
collection date through the duration of their hospitalization.
Patient CDCID:
20. Record laboratories documented as specified below.
Parameter
(include units)
Results on day
patient was
admitted to
hospital (if
multiple results,
select first
collected)
Results on day first
positive specimen
was collected
(select results
closest to specimen
collection)
Date: _/ /
Date: _/ /
Results of
highest value
obtained
during
hospitalizatio
n
Specify date
for each value
Results of
lowest value
obtained
during
hospitalization
Results on
day
discharged
from hospital
or died
Specify date
for each value
Date:
_/ /
WBC
Percent
neutrophils
(corresponds
to WBC count
above)
Percent bands
(corresponds
to WBC count
above)
Platelets
Hematocrit
BUN
Creatinine
Lactate
AST
ALT
INR
Alkaline
phosphatase
Bilirubin
Glucose
CRP
Anion Gap:
Sodium –
(Chloride +
Bicarbonate)
21. Was the patient admitted to an intensive care unit during his/her stay?
If yes, specify dates of admission to ICU:
1
2
3
4
Date of ICU Admit
/
/
/
/
/
/
/
/
Unk
Unk
Unk
Unk
Date of ICU Discharge
/
/
/
/
/
/
/
/
Unk
Unk
Unk
Unk
Yes
No
Unk
Patient CDCID:
22. Specify if any of the following procedures were performed or provided during the patient’s
hospitalization:
Procedure
Performed?
Date of
Procedure
If yes, describe
indication for
procedure
Indicate Start
Date for those
procedures
where number
of days is
documented
/
/
Placement of Chest
tube
Yes
Unk
No
Placement of other
drain
Specify
Yes
Unk
No
/
/
Acute hemodialysis
Yes
Unk
No
/
/
Mechanical
ventilation
Yes
Unk
No
/
/
Noninvasive
ventilation (CPAP or
BiPAP)
Yes
Unk
No
/
/
Placement of
Central Venous
Catheter
Bronchoscopy
Yes
Unk
No
/
/
Yes
Unk
No
/
/
Endoscopy
Specify
Yes
Unk
No
/
/
Surgery
Specify
Yes
Unk
No
/
/
Other
Specify
Yes
Unk
No
/
/
Other
Specify
Yes
Unk
No
/
/
Other
Specify
Yes
Unk
No
/
/
Number of Days
(do not fill if box
is greyed)
Patient CDCID:
23. Did the patient require vasopressors?
stop dates:
Yes
No
Unk If yes, specify which ones and all start and
List all vasopressors that were started at any point during the hospitalization. Each row is an event. If a
vasopressor was stopped and then restarted on a different date, the restart should be documented as a
separate entry.
Examples: Dopamine, Dobutamine, Epinephrine, Norepinephrine, Neosynephrine, Vasopressin, Other
(specify)
Vasopressor
Start date
/
/
/
/
/
/
/
/
/
/
/
/
Stop date
/
/
/
/
/
/
/
/
/
/
/
/
24. Using the medical administration record for inpatient hospitalization, specify all antibiotics received
during hospitalization. Complete one row for each antibiotic course. If four or more days between stop
and start then assume new antibiotic course and start new row.
Antimicrobial
Route (IV, IM, PO, Topical,
Inhaled)
IV
IM
PO
Topical
Inhaled
IV
IM
PO
Topical
Inhaled
IV
IM
PO
Topical
Inhaled
IV
IM
PO
Topical
Inhaled
IV
IM
PO
Topical
Inhaled
IV
IM
PO
Topical
Inhaled
IV
IM
PO
Topical
Inhaled
IV
IM
PO
Topical
Inhaled
IV
IM
PO
Topical
Inhaled
IV
IM
PO
Topical
Inhaled
Start date
Stop date
/
/
Unk
/
/
Unk
/
/
Unk
/
/
Unk
/
/
Unk
/
/
Unk
/
/
Unk
/
/
Unk
/
/
Unk
/
/
Unk
/
/
Unk
/
/
Unk
/
/
Unk
/
/
Unk
/
/
Unk
/
/
Unk
/
/
Unk
/
/
Unk
/
/
Unk
/
/
Unk
Patient CDCID:
25. Were antibiotics prescribed for patient at discharge?
a. If yes, specify:
Antimicrobial
Yes
No
Route (IV, IM, PO,
Topical)
Unk
Prescribed Duration in
Days (specify unknown if
not documented)
IV
IM
PO
Topical
Inhaled
IV
IM
PO
Topical
Inhaled
IV
IM
PO
Topical
Inhaled
Imaging
26. List all imaging studies and results
Note: Do not include results from X-Rays except Chest X-Ray as described in item 27
Performed
CT
MRI Ultrasound
Nuclear Medicine
Other (specify):
Location
Impression
Head
Abdomen
Chest
Extremity (specify):
Date
/
/
/
/
/
/
/
/
Other (specify):
CT
MRI Ultrasound
Nuclear Medicine
Other (specify):
Head
Abdomen
Chest
Extremity (specify):
Other (specify):
CT
MRI Ultrasound
Nuclear Medicine
Other (specify):
Head
Abdomen
Chest
Extremity (specify):
Other (specify):
CT MRI
Ultrasound
Nuclear Medicine
Other (specify):
Head
Abdomen
Chest
Extremity (specify):
Other (specify):
10
Patient CDCID:
CT
MRI Ultrasound
Nuclear Medicine
Other (specify):
Head
Abdomen
Chest
Extremity (specify):
/
/
/
/
/
/
/
/
Other (specify):
CT
MRI Ultrasound
Nuclear Medicine
Other (specify):
Head
Abdomen
Chest
Extremity (specify):
Other (specify):
CT
MRI Ultrasound
Nuclear Medicine
Other (specify):
Head
Abdomen
Chest
Extremity (specify):
Other (specify):
CT
MRI Ultrasound
Nuclear Medicine
Other (specify):
Head
Abdomen
Chest
Extremity (specify):
Other (specify):
27. Chest X-Ray (Document findings from the X-ray that was performed most proximal to the time the first
positive specimen was collected; only Chest X-rays on day of positive culture or the 2 days following)
Yes
No
Unk
If yes, specify date of Chest XRay:
/
/
Unk
Record impression:
Were any of the following noted (check all that apply; only check items that were explicitly documented by the
radiologist. Please also document their full written impression above)?
Pleural effusion
Infiltrate
No evidence of pneumonia
Consolidation
Bronchopneumonia/pneumonia
Cannot rule out pnemonia
11
Patient CDCID:
Procedures
28. Did patient have a lumbar puncture?
Yes
No
Unk
If yes, record results for each lumbar puncture performed (include units)
Date:
/
/
Parameter
WBC count
RBC count
Protein
Glucose
Opening pressure
Gram stain
Date:
/
/
Parameter
WBC count
RBC count
Protein
Glucose
Opening pressure
Gram stain
Unk
First tube
Subsequent tube
List differential
Unk
First tube
Subsequent tube
List differential
29. Did patient have paracentesis?
Yes
No
Unk
If yes, record results for each paracentesis performed (include units)
Date:
/
/
Parameter
WBC
RBC
LDH
Protein
Gram stain
Date:
/
Parameter
WBC
RBC
LDH
Protein
Gram stain
Unk
First tube
Differential:
/
Unk
First tube
Differential:
12
Patient CDCID:
30. Did patient have thoracentesis?
Yes
No
Unk
If yes, record results for each thoracentesis performed (include units)
Date:
/
/
Parameter
WBC
RBC
LDH
Protein
pH
Gram stain
Date:
/
Unk
First tube
Differential:
/
Parameter
WBC
RBC
LDH
Protein
pH
Gram stain
Unk
First tube
Differential:
31. Did patient have joint aspiration?
Yes
No
Unk
If yes, record results for each joint aspiration performed (include units)
Date:
/
/
Parameter
WBC
RBC
LDH
Protein
Gram stain
Date:
/
Parameter
WBC
RBC
LDH
Protein
Gram stain
Unk
First tube
Differential:
/
Unk
First tube
Differential:
13
Patient CDCID:
32. List all cultures (positive and negative) during the hospital course (Note: each set is one row)
Culture source
(specimen type)
Date
Result
If blood culture is a “set”
of cultures specify total
number of bottles and
the number positive
Unk
/
/
Unk
No growth
Organism specify
/
/
Unk
No growth
Organism specify
Unk
/
/
Unk
No growth
Organism specify
Unk
/
/
Unk
No growth
Organism specify
Unk
/
/
Unk
No growth
Organism specify
Unk
/
/
Unk
No growth
Organism specify
Unk
33. For E. anophelis isolates specify MIC or zone diameter and interpretation (if available) listed in the
medical record for first isolate
Isolate collection date
Piperacillin/tazobactam
Trimethoprim/sulfamethoxazole
Levofloxacin
Ciprofloxacin
Moxifloxacin
Rifampin
Vancomycin
Minocycline
Doxycycline
Date
/
Unk
/
Unk
/
Unk
/
Unk
/
Unk
/
Unk
/
Unk
/
Unk
/
Unk
MIC
Zone
Diameter
Interpretation
/
S
I
R
None
/
S
I
R
None
/
S
I
R
None
/
S
I
R
None
/
S
I
R
None
/
S
I
R
None
/
S
I
R
None
/
S
I
R
None
/
S
I
R
None
14
Patient CDCID:
Other (specify):
/
Unk
/
Unk
/
Unk
/
Unk
Other (specify):
Other (specify):
Other (specify):
a. What method was used? :
ATI
b. How was organism reported? Genus
/
S
I
R
None
/
S
I
R
None
/
S
I
R
None
/
S
I
R
None
Disc Diffusion/Kirby Bauer
Species
Other (specify)
Outcomes (at end of discharge from last short-stay acute care hospital):
34. Patient disposition:
Died
Discharged
Still inpatient at time of record review Unknown
Other (specify):
a. Date of discharge :
/
/
b. Date of death if not discharged:
/
/
Unk
c. Did patient die in the 30 days after discharge from the hospital (complete using information from
state vital records)?
Yes
No
Unk
a. If yes, specify
Date of death:
/
/
Unk
Cause(s) of death listed on death certificate in the order they are listed:
35. If discharged specify location of discharge:
Home
Long-term care facility
Long-term acute care hospital
Assisted living
Unk
Other, specify
36. Specify all discharge diagnoses in the order listed in the medical record:
37. Was patient readmitted to acute care hospital within 30 days from discharge from the hospital?
Yes
No
Unk
a. If yes, date of readmission
b. If yes, indication for readmission
15
Patient CDCID:
SECTION B
Compete Section B using all available records from the 30 days prior to the collection date of the first culture
positive specimen to complete the following section.
Did the patient receive any of the following medications in the 30 days prior to collection of the first positive
specimen?
38. H2 blocker:
Yes
No
Unk
If yes, were H2 blockers listed as outpatient medication in the HPI from the time of first positive culture
collection?
Yes
No
Unk
39. Proton pump inhibitor:
Yes
No
Unk
If yes, was the PPI listed as outpatient medication in the HPI from the time of first positive culture collection?
Yes
No
Unk
40. Were antibiotics administered during the 30 days prior to collection of positive culture, based on
provider notes
Yes
No
Unk
Do not include those already documented in item 24 above.
If yes, specify:
Antimicrobial
Amikacin
Amoxicillin
Route
IV
IV
IV
IM
IM
IM
PO
PO
PO
Topical
Topical
Topical
Inhaled
Inhaled
Inhaled
IV
IM
PO
Topical
Inhaled
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IM
IM
IM
IM
IM
IM
IM
IM
IM
IM
IM
IM
IM
IM
IM
IM
IM
IM
IM
IM
IM
IM
IM
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Start date
/
/
/
/
/
/
Unk
Unk
Unk
/
/
Unk
/
/
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Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Stop date
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Unk
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Unk
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Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Amoxicillin/Clavulanic
Acid
Ampicillin/sulbactam
Azithromycin
Aztreonam
Cefaclor
Cefazolin
Cefdinir
Cefepime
Cefotaxime
Cefpodoxime
Cefprozil
Ceftazidime
Ceftizoxime
Ceftriaxone
Cefuroxime
Cephalexin
Ciprofloxacin
Clarithromycin
Clindamycin
Colistin
Daptomycin
Doripenem
Doxycycline
Ertapenem
Fosfomycin
16
Patient CDCID:
Gentamicin
Imipenem
Levofloxacin
Linezolid
Meropenem
Metronidazole
Moxifloxacin
Nitrofurantoin
Ofloxacin
Penicillin
PiperacillinTazobactam
Polymyxin B
Rifampin
Tetracycline
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IV
IM
IM
IM
IM
IM
IM
IM
IM
IM
IM
IM
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
PO
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Topical
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
Inhaled
/
/
/
/
/
/
/
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/
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
/
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/
/
/
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/
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
IV
IV
IV
IV
IM
IM
IM
IM
PO
PO
PO
PO
Topical
Topical
Topical
Topical
Inhaled
Inhaled
Inhaled
Inhaled
/
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/
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/
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/
Unk
Unk
Unk
Unk
/
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/
Unk
Unk
Unk
Unk
IV
IV
IV
IM
IM
IM
PO
PO
PO
Topical
Topical
Topical
Inhaled
Inhaled
Inhaled
/
/
/
/
/
/
Unk
Unk
Unk
/
/
/
/
/
/
Unk
Unk
Unk
IV
IV
IM
IM
PO
PO
Topical
Topical
Inhaled
Inhaled
/
/
/
/
Unk
Unk
/
/
/
/
Unk
Unk
Other
(specify):
IV
IM
PO
Topical
Inhaled
/
/
Unk
/
/
Unk
Other
(specify):
IV
IM
PO
Topical
Inhaled
/
/
Unk
/
/
Unk
Other
(specify):
IV
IM
PO
Topical
Inhaled
/
/
Unk
/
/
Unk
Ticarcillin/Clavulanic
Acid
Tigecycline
Tobramycin
TrimethoprimSulfamethoxazole
Vancomycin
Other
(specify):
17
Form Approved
OMB# 0929-1011
Expires 03/31/2017
Appendix 2: Medical Abstraction Form
Public reporting burden of this collection of information is estimated to average 75 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)
Line list patient ID (CDCID) ___________
Wisconsin State Laboratory of Hygiene ID __________________ Abstractor Initials_________
This form is intended to be used for abstraction of medical records for patients in Wisconsin with:
·
Isolates of Elizabethkingia spp cultured from sterile sites,
AND
·
collected on or after November 1, 2015
Patient NAME: ______________________________________________________
Patient DOB: ___/___/_____ (MM/DD/YYYY)
MRN: ____________________________________________
Abstraction Information
Date medical record abstraction completed: ___/___/_____ (MM/DD/YYYY)
Abstractor:
Name: __________________________
Affiliation (state health dept. or CDC): __________________________________
Date_________
Line list patient ID (CDCID) ___________
Wisconsin State Laboratory of Hygiene ID __________________ Abstractor Initials_________
Line list patient ID (CDCID) ___________
Wisconsin State Laboratory of Hygiene ID __________________ Abstractor Initials_________
SECTION 1: Case Background Information. Complete this section using the Case Report Form
1. Date positive culture collected: ___/___/_____ (MM/DD/YYYY) Time positive culture collected (24 hour): HH:MM
2. First date of 30-day exposure period (date of culture collection – 30 days): ___/___/_____ (MM/DD/YYYY)
3. First date of 7-day exposure period (date of culture collection – 7 days): ___/___/_____ (MM/DD/YYYY)
4. Name of facility where first positive culture was collected: ____________________
LOCATION OF CULTURE COLLECTION:
Inpatient
Emergency Room
Observational unit/Clinical Decision Unit
Outpatient
Assisted Living
5.
6.
Was this collected more than 3 calendar days after admission:
Where was patient residing at time of culture collection:
Private residence
Acute care hospital inpatient
Homeless
Assisted living
7.
8.
9.
LTCF/SNF
LTACH
Dialysis clinic
Unknown
Yes
No
LTCF/SNF
LTACH
Other
Unknown
Was the patient hospitalized for Elizabethkingia infection?
Yes
No
If yes to 5: Admission date: ___/___/_____ (MM/DD/YYYY)
Admission time(24 hour): ______HH:MM
If culture was not collected in a hospital facility, what was the reason for culture? ___________________________
Line list patient ID (CDCID) ___________
Wisconsin State Laboratory of Hygiene ID __________________ Abstractor Initials_________
10. Please list all known medical encounters in 30 days prior. Medical records should be requested from each of the listed facilities.
HC
Date of Health
Care
Encounter #
Type of encounter
Record or interview included, Yes or No
Encounter location
Encounter
1
2
3
4
5
outpatient clinic
home health
EMS
emergency room (no admy to ACH)
ACH (admission )
Assisted living
LTCF
LTACH
Dialysis
Dental
Other
If admitted:
Dates __/__/____- __/__/____
outpatient clinic
home health
EMS
emergency room (no admy to ACH)
ACH (admission )
Assisted living
LTCF
LTACH
Dialysis
Dental
Other
If admitted:
Dates __/__/____- __/__/____
outpatient clinic
home health
EMS
emergency room (no admy to ACH)
ACH (admission )
Assisted living
LTCF
LTACH
Dialysis
Dental
Other
If admitted:
Dates __/__/____- __/__/____
outpatient clinic
home health
EMS
emergency room (no admy to ACH)
ACH (admission )
Assisted living
LTCF
LTACH
Dialysis
Dental
Other
If admitted:
Dates __/__/____- __/__/____
outpatient clinic
home health
EMS
emergency room (no admy to ACH)
ACH (admission )
Assisted living
LTCF
LTACH
Dialysis
Dental
Other
If admitted:
Dates __/__/____- __/__/____
Line list patient ID (CDCID) ___________
Wisconsin State Laboratory of Hygiene ID __________________ Abstractor Initials_________
SECTION 2: Overall Medical History. Complete this section using all available medical records
Medical History
11. Females only: Were you pregnant or ≤6 weeks postpartum at the time of first positive EK culture?
Yes, pregnant (weeks pregnant at onset)______
Yes, postpartum (delivery date) ___/___/____
No
Unk
12. Height (use record closest to EK positive culture) _____ft ________in ________cm
13. Weight (use record closest to EK positive culture) ________lb _____________kg
14. BMI ________________
15. Did the patient have any of the following medical conditions? Specify ALL conditions that are present.
Coronary artery disease
Connective Tissue Disease
Atrial Fibrillation
Malignant Lymphoma
Congestive Heart Failure
Solid Tumor
Peripheral Vascular Disease
Mild Liver Disease
Cerebrovascular Disease
HIV without AIDS
Dementia
AIDS
Chronic Obstructive Pulmonary Disease (COPD)
History of decubitus ulcers
Pulmonary Hypertension
Cellulitis
Peptic Ulcer Disease
Pancreatitis
Diabetes Mellitus without complications
Current alcohol dependence
moderate or severe renal disease
Inflammatory bowel disease(Ulcerative Colitis/Crohns)
Hemiplegia
Smoking (previous year)
Hematologic Malignancy
Solid organ transplant
Moderate or severe liver disease
Asthma
Diabetes mellitus with end organ damage
Other ___________________________________________
Dialysis
16. Did the patient get dialysis in the 30 days prior to positive EKM culture?
Yes
No
Unknown
Hemodialysis
Peritoneal
Unknown
a. What type of dialysis was performed?
Yes
No
Unknown
b. Does the patient have permanent vascular access?
AV fistula/graft
CVC
Unknown
c. What type of vascular access was used?
Yes
No
d. Did the patient get this type of dialysis in the 7 days prior to positive EKM culture?
i. Date of most recent dialysis _________________
Dialysis Center (Name______________________________)
ii. Location
Emergency Department (Name______________________________)
Home *note: peritoneal dialysis is usually done at home
Other: _____________________________
Yes
17. Did the patient have CRRT in the 30 days prior to positive EK culture?
e. Date _____________________________________________
f. Name of facility: ___________________________________
NO
Unk
Line list patient ID (CDCID) ___________
Wisconsin State Laboratory of Hygiene ID __________________ Abstractor Initials_________
Yes
18. Did the patient receive any IV or IM medications in the 30 days to 2 hours prior to positive culture?
If yes, complete the table below:
Facility Name
Most Recent
Route (IV,
Date Prior to
Approximate start
Medication Name
IM)
Positive Cx
date
(MM/DD?YYY)
19. Did the patient have surgery in the 30 days prior to positive EK culture?
Type of Surgery
Date (MM/DD/YYY)
Yes
No
Facility Name
20. Did patient have a wound in the thirty days prior to positive culture: Yes or No
a. Wound type (description and location) _________________________________________
b. Topical treatments received: _________________________________________________
No
Comments
Line list patient ID (CDCID) ___________
Wisconsin State Laboratory of Hygiene ID __________________ Abstractor Initials_________
21. Did patient have any indwelling devices present in the 30 days prior
Yes
No
Device
Present at EK Cx?
Details
Yes
No
Unk
Cardiac Pacemaker/ICD
Yes
No
Unk
Cardiac Defibrillator
Yes
No
Unk
Prosthetic Cardiac Valve
Yes
No
Unk
Vascular Stent
cardiac
peripheral
other_________
Yes
No
Unk
Vascular grafts
cardiac
aortic
other_________
Yes
No
Unk
Indwelling vascular catheter
Port
Picc
HD permcath
other __________
Yes
No
Unk
Urinary Catheter
Yes
No
Unk
Prosthetic joint
Location: ______________________
Yes
No
Unk
Orthopedic implants
(plates/screws)
Yes
No
Unk
Other Implant1
Yes
No
Unk
Other Implant2
Placed in last 30 days?
Yes
Yes
Yes
Yes
No
No
No
No
Unk
Unk
Unk
Unk
Yes
Yes
No
No
Unk
Unk
Yes
Yes
Yes
No
No
No
Unk
Unk
Unk
Yes
Yes
No
No
Unk
Unk
Yes
No
22. Has patient used any immunosuppressant medications in the last 30 days:
Immunosuppressant
In 30 days prior to Cx?
Medication name
Date of most recent administration
Corticosteroid (e.g. Predisone >20mg daily)
Yes
No
Biologics
Yes
No
Chemotherapy
Yes
No
Radiation
Yes
No
Other1
Yes
No
Other2
Yes
No
*examples of common biologics include Humira (adalimumab), Remicade (infliximab), Rituxan (rituximab), Enbrel (etanercept), or
other medications ending in –mab or –cept
Line list patient ID (CDCID) ___________
Wisconsin State Laboratory of Hygiene ID __________________ Abstractor Initials_________
23.Culture Data: Complete for all cultures collected 7 days prior to positive EK culture (EXCEPT EK POSTIVE CULTURES)
Culture
No.
1
2
3
4
5
6
7
8
9
10
Specimen
Blood
Urine
BAL
CSF
Ascites
Blood
Urine
BAL
CSF
Ascites
Blood
Urine
BAL
CSF
Ascites
Blood
Urine
BAL
CSF
Ascites
Blood
Urine
BAL
CSF
Ascites
Blood
Urine
BAL
CSF
Ascites
Blood
Urine
BAL
CSF
Ascites
Blood
Urine
BAL
CSF
Ascites
Blood
Urine
BAL
CSF
Ascites
Blood
Urine
BAL
CSF
Ascites
Pleural fluid
Synovial fluid
Wound
Stool
Sputum
Pleural fluid
Synovial fluid
Wound
Stool
Sputum
Pleural fluid
Synovial fluid
Wound
Stool
Sputum
Pleural fluid
Synovial fluid
Wound
Stool
Sputum
Pleural fluid
Synovial fluid
Wound
Stool
Sputum
Pleural fluid
Synovial fluid
Wound
Stool
Sputum
Pleural fluid
Synovial fluid
Wound
Stool
Sputum
Pleural fluid
Synovial fluid
Wound
Stool
Sputum
Pleural fluid
Synovial fluid
Wound
Stool
Sputum
Pleural fluid
Synovial fluid
Wound
Stool
Sputum
Collect date
(mm/dd/yy)
Time (HH:MM)
____ / ___ / ___
___:___
____ / ___ / ___
___:___
____ / ___ / ___
___:___
____ / ___ / ___
___:___
____ / ___ / ___
___:___
____ / ___ / ___
___:___
____ / ___ / ___
___:___
____ / ___ / ___
___:___
____ / ___ / ___
___:___
____ / ___ / ___
___:___
Pathogens identified
CX is Neg
Path1 _______________________________
Path2 _______________________________
Path3 _______________________________
CX is Neg
Path1 _______________________________
Path2 _______________________________
Path3 _______________________________
CX is Neg
Path1 _______________________________
Path2 _______________________________
Path3 _______________________________
CX is Neg
Path1 _______________________________
Path2 _______________________________
Path3 _______________________________
CX is Neg
Path1 _______________________________
Path2 _______________________________
Path3 _______________________________
CX is Neg
Path1 _______________________________
Path2 _______________________________
Path3 _______________________________
CX is Neg
Path1 _______________________________
Path2 _______________________________
Path3 _______________________________
CX is Neg
Path1 _______________________________
Path2 _______________________________
Path3 _______________________________
CX is Neg
Path1 _______________________________
Path2 _______________________________
Path3 _______________________________
CX is Neg
Path1 _______________________________
Path2 _______________________________
Path3 _______________________________
Line list patient ID (CDCID) ___________
Wisconsin State Laboratory of Hygiene ID __________________ Abstractor Initials_________
24.Culture Data: Complete for all positive EK cultures
Culture
No.
1
2
3
4
5
Specimen
Blood
Urine
BAL
CSF
Ascites
Blood
Urine
BAL
CSF
Ascites
Blood
Urine
BAL
CSF
Ascites
Blood
Urine
BAL
CSF
Ascites
Blood
Urine
BAL
CSF
Ascites
Pleural fluid
Synovial fluid
Wound
Stool
Sputum
Pleural fluid
Synovial fluid
Wound
Stool
Sputum
Pleural fluid
Synovial fluid
Wound
Stool
Sputum
Pleural fluid
Synovial fluid
Wound
Stool
Sputum
Pleural fluid
Synovial fluid
Wound
Stool
Sputum
Collect date
(mm/dd/yy)
Time (HH:MM)
____ / ___ / ___
___:___
____ / ___ / ___
___:___
____ / ___ / ___
___:___
____ / ___ / ___
___:___
____ / ___ / ___
___:___
Comments
Line list patient ID (CDCID) ___________
Section III: Visit with the positive culture.
Location of visit:
acute care hospital
Skilled Nursing Facility
Wisconsin State Laboratory of Hygiene ID __________________ Abstractor Initials_________
LTACH
Urgent Care
Dialysis Center
Outpatient Clinic
Assisted living
Other _________________________________________________
Date of symptom onset (for positive culture): __________________________
25.
Chief Complaint (i.e. what were the patient’s symptoms) at time of positive culture:
Approximate Start Date (MM/DD/YYY)
Abdominal Pain
Altered Mental Status
Chest Pain
Cough
Diarrhea
Dysuria
Facial Droop
Fever
Hyperglycemia
Rash/Redness
Tachypnea/Dyspnea/Shortness of Breath
Swelling
Vomiting/Nausea
Weakness
None, Asymptomatic
Other1______
Other2_______
a.
26.
If patient asymptomatic did the patient develop signs of infection later?
Yes
No
Unk
i. If yes, what were the symptom(s)_________________________________________________________?
ii. What day did symptoms develop? ___________________(MM/DD/YYY)
Patient Labs & Vitals within 2 hours of culture collection
Value
Date: _____________MMDDYY
Temperature
Heart Rate
Blood Pressure
Respiratory Rate
Pulse Ox
Lactate
WBC
Time:____:_____
27.
Diagnosis for the visit when the positive culture was collected:
Acute Respiratory Failure
Pleural Effusion
Atrial Fibrillation
Pneumothorax
Bacteremia
Renal Failure
Cellulitis
Sepsis
DKA
Stroke
Heart Failure
UTI
Hyperglycemia
Other1: ________
Myocardial Infarction
Other2:_______
28. Was Patient Admitted in response to the positive culture?
Yes
No
29. Did the patient have evidence of soft tissue infection at time of positive culture: Yes or No
a. If yes, describe: _______________________________________
Line list patient ID (CDCID) ___________
Wisconsin State Laboratory of Hygiene ID __________________ Abstractor Initials_________
30. Did the patient have diagnosed pulmonary infection at time of positive culture? Yes or No
a. If yes, describe: _______________________________________
31. Did the patient have any other infections at time of positive culture? Yes or No?
a. If yes, describe: _______________________________________
32. What was patient’s disposition from hospitalization in which EK positive culture was collected?
33.
Death
Home
Inpatient rehab
LTCF/SNF
Hospice
Other: _______
34. If the patient Died : Date of death____/____/_____ (MM/DD/YYYY)
home
Inpatient rehab
LTCF/SNF
hospice
Other: ________
35. Location of death:
36. Diagnosis at time of death? __________________
Line list patient ID (CDCID) ___________
Wisconsin State Laboratory of Hygiene ID __________________ Abstractor Initials_________
Section IV: Complete one Healthcare Facility form for EACH healthcare facility the patient visited in the 30 days prior to positive EK
culture
Name of Facility/Clinic________________________________________
acute care Hospital
University Hospital
Dialysis Center
Outpatient Clinic
Dental Office
Facility type:
Skilled Nursing Facility
Urgent Care
Other _________________________________________________
Date(s) of visit to healthcare facility: ____/____/_____ (MM/DD/YYYY)
Inpatient or outpatient: ______________________________________________________________
If inpatient, date of admission: ____/____/_____ (MM/DD/YYYY)
If inpatient, date of discharge: ____/____/_____ (MM/DD/YYYY)
Reason for visit or chief complaint: ___________________________________________________
Percutaneous Exposures
1.
IV infusion
Date
(MM/DD/YYYY)
Yes
Notes
No
Specify products used
Infusate:
Antiseptic:
2.
IM injection
Yes
No
Infusate:
Antiseptic:
3.
4.
5.
6.
7.
8.
9.
10.
Thoracentesis
Paracentesis
Peripheral IV insertion
Central line placement.
Type 1:
Central line placement.
Type 2:
Interventional Radiology
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Specify antiseptic
Specify antiseptic
Specify antiseptic
Specify antiseptic
Infusate:
Antiseptic:
11. Radiology with contrast
Yes
No
Infusate:
Antiseptic:
12. Labs Drawn
13. Bedside tests (e.g. Blood
glucose, lactate)
14. Other
1(specify)___________
15. Other 2
(specify)___________
16. Other 3
(specify)___________
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Specify:
Specify:
Specify antiseptic
Specify antiseptic
Line list patient ID (CDCID) ___________
Respiratory Exposures
17. Oxygen Administered (e.g
face mask, nasal cannula)
18. Intubation
19. Nebulizer
20. Metered Dose Inhaler (MDI)
21. Other(specify)_____________
Topical Exposures
22. Podiatry care
Wisconsin State Laboratory of Hygiene ID __________________ Abstractor Initials_________
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
23. Whirlpool therapy
24. Any topical treatments
Other exposures:
Yes
No
Yes
No
25. Endoscopy
26. Other exposure 1
Yes
No
Yes
No
Specify agent
Specify agent
Specify any topical
treatments
Specify:
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
2016 Urgent Assessment of Blood Collection and Use in Puerto
Rico in Response to the Zika Virus Outbreak
Public reporting burden of this collection of information is estimated to average 60 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)
¡Hola!
Please fill out the following sections that pertain to your institution as
completely as possible. The arrows will help you progress through the
survey. In general, Section 2 corresponds to Blood Collections and
Section 3 corresponds to Blood Transfusions.
Please complete and return to the below email by February 19, 2016
Amber Vasquez, MD, MPH
Zika Blood Safety Team
email: [email protected]
cell: 937-269-3169
Please do not hesitate to call or email with questions.
Contact Information
Primary person responsible for completing this section
Prefix
First name
Last name
Title/Position
Name of Institution
Address of Institution
Telephone
Email
Facility included in the survey
Facility name
Address
orgid: 101
General Information
Which of the following best describes your institution?
Select one (with "X")
A local or regional blood center (non-hospital) that collects blood from donors and supplies blood and
components to other institutions, but does not perform transfusion services
A hospital-based blood bank and transfusion service that collects blood from donors (may be only autologous
or directed) and provides blood and components for transfusion primarily to your own institution
A transfusion service that provides blood and components for transfusion, but does not collect blood from
donors
A local or regional blood center that collects blood from donors and supplies blood, components, and cross
matched blood products to participating facilities (e.g., centralized transfusion services). In this category, the
service is not limited to reference laboratory work, but includes routine transfusion service work
Yes/No
Does your institution collect blood from donors?
(Even if you collect autologous units only, enter “Yes.”)
Section 2 Blood collections
From Jan 1, 2015 through Dec 31, 2015, how many collections were successfully
completed by your institution in each of the following categories? (*indicates required
fields)
Whole Blood
Allogeneic (non-directed donations)*
Autologous*
Directed*
Total*
Red Blood Cells
Apheresis
Allogeneic*
Autologous*
Directed*
Concurrent red cells (from apheresis platelets)
Total Apheresis Red Blood Cells*
Whole-blood-derived
Allogeneic*
Autologous*
Directed*
Total WBD Red Blood Cells*
Platelets
Apheresis
Single-donor
Directed single-donor
Single collection
Double collection1
Triple collection1
Total Apheresis Platelets*
Total apheresis platelet units subjected to pathogen reduction technology
Whole-blood-derived
Individual*2
Total whole blood-derived individual units subjected to pathogen reduction technology
Plasma
Apheresis
FFP
PF24
PF24RT24
Jumbo FFP (>400 mL)
Total Apheresis Plasma*
Total Apheresis plasma units subjected to pathogen reduction technology
Whole-blood-derived
FFP
PF24
Cryoprecipitate reduced
Liquid
Total WBD Plasma*
Total WBD plasma units subjected to pathogen reduction technology
Cryoprecipitate
Individual*3
Total Granulocytes*
1
Count double collections as two units and triple collections as three units
Enter the number of individual platelet units prepared from whole blood collections
3
Enter the number of individual cryoprecipitate units prepared from whole blood collections
2
Number of Collection Procedures* Number of Units
2.3 Blood collections
2.3. From Jan 1, 2015 through Dec 31, 2015, from how many of the following types of donors
did your institution successfully collect blood?
First-time allogeneic donors
Repeat allogeneic donors (Count multiple donations from a single repeat donor only once)
Directed donors
Autologous donors
Total number of donors
Number of Donors
2.4 Blood collections
From Jan 1, 2015 through Dec 31, 2015, how many units of each product were imported,
distributed, and outdated by your institution? (* indicate required fields)
Whole Blood for distribution as Whole Blood
Allogeneic (non-directed donations)
Autologous
Directed
Total*
Red Blood Cells
Apheresis
Allogeneic
Autologous
Directed
Concurrent red cells (from
Total Apheresis Red Blood Cells*
Whole-blood-derived
Allogeneic
Autologous
Directed
Total WBD Red Blood Cells*
Platelets
Apheresis
Single-donor
Directed single-donor
Single collection
2
Double collection
Triple collection2
Total Apheresis Platelets*
Whole-blood-derived
Individual*
Pooled3
Plasma
Apheresis
FFP
PF24
PF24RT24
Jumbo FFP (>400 mL)
Total Apheresis Plasma*
Whole-blood-derived
FFP
PF24
Cryoprecipitate reduced
Liquid
Total WBD Plasma*
Cryoprecipitate
Individual*
Pooled4
Total Granulocytes*
1
Units returned and distributed more than once should be counted only once
Count double collections as two units and triple collections as three units
Total number of platelet pools prepared from whole blood collections
4
Total number of cryoprecipitate pools prepared from whole blood collections
2
3
Total Units Imported
Total Units Distributed
(including imported
units)1
Total Units
Outdated
2.5-2.6 Blood collections
2.5 What was the average whole dollar amount your institution was reimbursed (by
hospital or clinical facility) per unit in 2015 for the following components? (Include
discounts in your calculations. If you do not use a particular component, select “Not
Applicable”. CPT/HCPCS codes are in in parenthesis.)
Average Amount
Paid Per Unit ($)
Plasma, single donor, frozen with 8 hours of phlebotomy (P9017)
Plasma, frozen between 8 and 24 hours of phlebotomy (P9059)
Red cells, leuko-reduced (P9016)
Red cells, non-leuko-reduced (P9021)
WBD platelets, each unit, not leuko-reduced, not irradiated (P9019)
Apheresis platelets, leuko-reduced (P9035)
Cryoprecipitate, each unit (P9012)
2.6. If your facility does not use pathogen reduction technology for apheresis platelet or
plasma collections...
What is the estimated total cost of implementation (this includes equipment, capital investment,
training, etc)?
What is the estimated additional cost per each unit type below if your facility adopted pathogen
reduction technology?
Cost
Section 3 - Blood utilization
Yes/No
Is your institution directly involved in the transfusion of blood to patients?
3.3 Blood utilization
3.3. From Jan 1, 2015 through Dec 31, 2015, how many units of allogeneic
whole blood and red blood cells did your institution transfuse? (Leave the
field blank if you do not know the answer).
Allogeneic Whole Blood
Allogeneic Red Blood Cells (include all blood groups)
Allogeneic Group O Positive RBCs
Allogeneic Group O Negative RBCs
Allogeneic Group A Positive RBCs
Allogeneic Group A Negative RBCs
Allogeneic Group B Positive RBCs
Allogeneic Group B Negative RBCs
Allogeneic Group AB Positive RBCs
Allogeneic Group AB Negative RBCs
Total Number of Total number
Units Transfused of Recipients
Total
outdated
units
3.4 Blood utilization
3.4. Indicate the disposition of directed and autologous units in 2015
Directed Whole Blood Units
Directed RBC Units
Autologous Whole Blood Units
Autologous RBC Units
Total Number of Units
Total Number
Transfused to Intended
of Recipients
Recipient
Outdated
Units
3.5 Blood utilization
3.5. From Jan 1, 2015 through Dec 31, 2015, how many units of each of the
following components did your institution transfuse and how many units
were outdated while on your shelf (include units transfused to pediatric
patients)? (* indicates required fields)
WBD Platelets (individual concentrates and pools expressed as individual
concentrate equivalents)*
Apheresis Platelet units – Full dose*
Directed Platelets to intended recipients
Total Plasma*
Fresh Frozen Plasma (FFP)
FFP, pediatric size (≤100 mL)
Plasma, Frozen within 24 hours (PF24)
PF24RT24
Jumbo FFP (>400 mL)
Liquid plasma
Directed plasma to intended recipients
Thawed plasma
Plasma, cryoprecipitate reduced
Group AB plasma
Granulocytes*
Platelets with pathogen reduction technology
Plasma with pathogen reduction technology
Total Number of Units
Transfused
Total Number
of Units
Outdated
3.6 Blood utilization
3.6. Indicate the total number of units transfused to pediatric
populations in 2015
Whole Blood
RBCs
Plasma
Platelets
1
This should be a subset of data reported in question 4 and 5 if your hospital
transfuses non-pediatric patients.
Number of Adult Equivalent
Units in Whole or in Part for
Pediatric Patients1
Total Number of
Pediatric
Recipients
3.7 Blood utilization
3.7. Indicate how many irradiated, leuko-reduced, and leuko-filtered units for each of the
following components your institution transfused in 2015. For pediatrics, use the number of
adult equivalent units used in whole or part. For components that are irradiated and leukoreduced, include these in the count for both columns.
a.
Whole Blood
b.
RBCs
c.
Apheresis platelets (single donor platelets)
d.
WBD platelets
Total components (if the number for a-d is ‘unknown’, enter the total number of components for the
modification)
Components
Irradiated
Components LeukoComponents Leukoreduced Before or
filtered at the
After Storage (not at
Bedside
bedside)
3.8-3.9 Blood utilization
Yes/No
3.8. Does your institution have a policy to transfuse only leuko-reduced (LR)
components?
3.9a. In 2015, how many total units of RBCs transfused were…
Number of Units
1 – 35 day(s) old
36 – 42 days old
3.9b. In 2015, how many total units of WBD platelets transfused were…
1 – 3 day(s) old
4 – 5 days old
3.9c. In 2015, how many total units of Apheresis platelets transfused were…
1 – 3 day(s) old
4 – 5 days old
Number of Units
Number of Units
3.10-3.11 Blood utilization
Number of
platelet units
3.10. In your institution, on average, how many individual platelet units were
included in a pooled WBD platelet dose in 2015?
3.11. Indicate the number of units that were transfused in inpatient or
outpatient settings.
All Surgery (including transplant)
Inpatient Medicine (including hematology/oncology)
Emergency Department
Obstetrics/Gynecology
Pregnant females
Pediatrics
Neonates
Outpatient and non-acute inpatient settings1
1
E.g., outpatient dialysis, rehabilitation, long term care, etc.
Number of RBC
Number of
Units
Platelet Units
Total
Don’t Know
3.12 Blood utilization
3.12. What was the average whole dollar amount your institution paid per
unit in 2015 for the following components? (Include discounts in your
calculations. If you do not use a particular component, select “Not
Applicable”. CPT/HCPCS codes are in in parenthesis.)
Plasma, single donor, frozen with 8 hours of phlebotomy (P9017)
Plasma, frozen between 8 and 24 hours of phlebotomy (P9059)
Red cells, leuko-reduced (P9016)
Red cells, non-leuko-reduced (P9021)
WBD platelets, each unit, not leuko-reduced, not irradiated (P9019)
Apheresis platelets, leuko-reduced (P9035)
Cryoprecipitate, each unit (P9012)
Average Amount Paid
Per Unit ($)
3.13 Blood utilization
Yes/No
3.13a. Were any elective surgeries postponed due to blood inventory
shortages in 2015?
Number of days
3.13b. How many days were elective surgeries postponed?
Number of surgeries
3.13c. How many elective surgeries were postponed in 2015?
3.16 - 3.17 Blood utilization
16. In 2015, how many days was your institution’s order incomplete for the
following components?
Number of days
Whole Blood
RBCs
Plasma
Apheresis platelets
WBD platelets
Number of days
17. In 2015, how many days were you unable to meet other non-surgical blood
requests (e.g., red cells, platelets)?
3.18-3.20 Blood utilization
Number of units
18. At your institution, how many units of Group O red cells are on your shelf on
an average weekday?
Number of units
19. At what number of Group O positive and Group O negative RBC units in
uncrossmatched inventory do you consider your inventory to be “critically low”?
Yes/No
20. Does your facility have an electronic system for tracking transfusion-related
adverse events (e.g., unplanned, unexpected, and undesired occurrences)?
3.21 Blood utilization
Number of units
3.21a. How many total red blood cell units did you buy from a non-American Red
Cross blood center in 2015?
Number of units
3.21b. How many total red blood cell units did you buy from an American Red Cross
blood center in 2015?
Survey Completed!
Thank you for taking the time to complete this survey.
Please return to the below email by February 19, 2016
Amber Vasquez, MD, MPH
Zika Blood Safety Team
email: [email protected]
cell: 937-269-3169
Please do not hesitate to call or email with questions.
Survey Glossary
Autologous: Self-directed donations.
Centralized transfusion service: A hospital or blood center that collects blood from donors and supplies blood,
components, medical services and/or crossmatched blood products to multiple transfusing facilities.
Collected: Successful whole blood or apheresis collections placed into production (not QNS, or other removals).
Deferrals: The number of donors deferred for specific reasons:
a) Donors deferred for low hemoglobin do not meet the current FDA blood hemoglobin level requirements for
blood
donation.
b) Deferrals
for other medical reasons may include the use of medications on the medication deferral list, growth
hormone from human pituitary glands, insulin from cows (bovine, or beef, insulin), Hepatitis B Immune Globulin
(HBIG), unlicensed vaccines, or presenting with physical conditions or symptoms that do not qualify a person to be a
blood donor.
c) High-risk behavior deferrals include deferrals intended to reduce the risk of transmission of infectious diseases
including HIV and hepatitis viruses. Examples of questions intended to identify these risks are sexual contact (e.g.,
men who have sex with men (MSM)) and non-medical injection drug use questions.
d) Travel deferrals are deferrals for travel to a specific region of the world.
Directed: Allogeneic donations intended for a specific patient.
Donation: The collection of a unit of blood or blood component from a volunteer donor.
Dose/Dosage: a quantity administered at one time, such as a specified volume of platelet concentrates.
First-time allogeneic donor: A donor who is donating for the first time at your center.
Imported: Units not collected by your institution, but obtained by your institution from another institution for
distribution to a transfusion facility.
Modify: Procedures applied by a blood center, hospital blood bank, or transfusion service that may affect the quality
or quantity of the final product (e.g., irradiation, leukofiltration, or production of aliquots of lesser volume).
Outdated: Units that expire on your shelf.
Plasma:
a) Plasma, frozen within 24 hours of phlebotomy (PF24): plasma separated from the blood of an individual donor
and placed at -18 C or colder within 24 hours of collection from the donor.
b) Fresh frozen plasma (FFP): Plasma frozen within 8 hours of collection.
c) Plasma, Jumbo: FFP having a volume greater than 400 mL.
d) Plasma frozen within 24 hours of phlebotomy and held at room temperature up to 24 hours after phlebotomy
(PF24RT24): Plasma held at room temperature for up to 24 hours after collection and then frozen at -18 C or colder.
Recipient: A unique individual patient receiving a transfusion one or more times in a calendar year.
Distributed: units that have fulfilled all processing requirements and have been made available for transfer to
customers.
Repeat allogeneic donor: A donor who has previously donated a blood component.
Severe Donor-Related Adverse Events: adverse events occurring in donors attributed to the donation process that
include, for example, major allergic reaction, arterial puncture, loss of consciousness of a minute or more, loss of
consciousness with injury, nerve irritation, etc.
Transfusion Related Adverse Reactions: An undesirable response or effect in a patient temporally associated with the
administration of blood or blood components. For a list of adverse reaction types and case definitions, visit
http://www.cdc.gov/nhsn/PDFs/Biovigilance/BV-HV-protocol-current.pdf.
Transfusion Service: a facility that performs, or is responsible for the performance of, the storage, selection, and
issuance of blood and blood components to intended recipients.
Study ID #: _CHÿÿÿ
Appendix 1. Invasive GAS in Long Term Care Facility 2016
Employee Survey
Form Approved; OMB No. 0920-1011
Exp. Date 03/31/2017
□ Check box if documented case
Date Completed: ____/____/____
A. Employee Background
3. Sex:
ÿ Male
2. Age:
1. Name:
ÿ Female
4. Employed at Facility since: ______/______/______
5. List occupation: ÿ Activity aid
ÿ Administrative
ÿ CNA
ÿ Dietary
ÿ Food service
ÿ Housekeeping
ÿ Laundry
ÿ PT/OT
ÿ Pharmacist
ÿ Physician
ÿ Maintenance
ÿ RNA
ÿ RN/LPN
ÿ Social service ÿ Van driver
ÿ Wound care team
ÿ Other __________________________
ÿ Yes
6. Since Thanksgiving to present, have you worked in any other patient-care facility?
Name & city of facility
Dates of employment
Have you been in contact with a
patient infected with group A strep?
What was the patient’s diagnosis?
Start:
____ / _____ / _______
End:
____ / _____ / _______
ÿ Yes
ÿ Strep throat
ÿ Impetigo
ÿ No
ÿ Cellulitis
ÿ Bacteremia/Sepsis
If yes, date of contact:
____ / _____ / _______
ÿ Other, specify: ________________
ÿ Yes
ÿ Strep throat
ÿ Impetigo
ÿ No
If yes, date of contact:
____ / _____ / _______
ÿ Cellulitis
ÿ Bacteremia/Sepsis
ÿ Yes
ÿ Strep throat
ÿ Impetigo
ÿ No
ÿ Cellulitis
ÿ Bacteremia/Sepsis
If yes, date of contact:
____ / _____ / _______
ÿ Other, specify: ________________
Start:
____ / _____ / _______
End:
____ / _____ / _______
Start:
____ / _____ / _______
End:
____ / _____ / _______
7.
ÿ No (If no, skip to Section B)
ÿ Other, specify: ________________
a. Since the outbreak, have you had a screening culture for group A Streptococcus?
ÿ Yes
ÿ No
(If no, skip to # 8)
b. If yes, when? ______ / _______ / _______
c. Where was the culture obtained from?
d. What were the results?
ÿ Positive
B. Job Description at
Facility A
9. Areas usually worked:
ÿ Throat
ÿ Rectal
ÿ Vaginal
ÿ Skin/wound
ÿ Other
ÿ Negative
8. As part of your job, do you have physical contact with patients?
ÿ Yes
ÿ No
(If no, skip to Section D)
ÿ Patient rooms
10. Shifts usually worked:
ÿ Day
ÿ Nurses’ station
ÿ Evening
ÿ Night
ÿ Cafeteria ÿ Rehab floor ÿ Other _____________________
ÿ Other________________________
11. Patient units usually worked: ÿ 1 ÿ 2 ÿ 3 ÿ 4 ÿ 5 ÿ 6 ÿ 7 ÿ 8 ÿ Do not work in patient units ÿ All patient units
12. Which days do you usually work (circle ALL that apply):
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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)
13. What kind of patient contact do you have? (check ALL that apply)
ÿ Give oral medications
ÿ Feeding resident
ÿ Change dressings/wound care
ÿ Gastrostomy care ÿ Handle urinary catheter
ÿ Bathe resident
ÿ Assist with patient transfer
ÿ Clean room
ÿ Handle soiled linens/bedding
ÿ Handle soiled diapers/bedpans
ÿ Deliver meal trays
ÿ Take vital signs
ÿ Bedside incision and debridement aspiration/drainage
ÿ Provide PT/OT
ÿ Other beside surgical procedures
C. Work Practice
ÿ Respiratory therapy
ÿ Tracheostomy care
14. Do you use soap and water to clean your hands?
15. Do you use alcohol-based hand sanitizer to clean your hands?
16. Please answer the following questions
(circle answer)
ÿ No
ÿ Yes
ÿ No
Never
Always
a.
Do you perform hand hygiene BEFORE physical contact with patients?
1
2
3
4
5
N/A
b.
Do you perform hand hygiene BEFORE physical contact with each patient’s
environment or belongings (e.g. bedside table, refrigerator, rolling walker, etc.)?
1
2
3
4
5
N/A
c.
Do you perform hand hygiene AFTER physical contact with patients?
1
2
3
4
5
N/A
d.
Do you perform hand hygiene AFTER physical contact with each patient’s environment
or belongings (e.g. bedside table, refrigerator, rolling walker, etc.)?
1
2
3
4
5
N/A
e.
Do you perform hand hygiene BETWEEN contact with patients?
1
2
3
4
5
N/A
f.
Do you use the sink or alcohol-based sanitizer in the patient’s room or outside patient’s
room?
1
2
3
4
5
N/A
g.
Do you use the sink or alcohol-based sanitizer at the nurse’s station?
1
2
3
4
5
N/A
h.
Do you use gloves when changing bandages/dressing wounds?
i. If yes, do you change gloves between patients/patient rooms?
j. If yes, do you perform hand hygiene before donning gloves?
k. If yes, do you perform hand hygiene after removing gloves?
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
5
5
5
5
N/A
N/A
N/A
N/A
l.
Do you use gloves when cleaning soiled patients or linens?
m. If yes, do you change gloves between patients/patient rooms?
n. If yes, do you perform hand hygiene before donning gloves?
o. If yes, do you perform hand hygiene after removing gloves?
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
5
5
5
5
N/A
N/A
N/A
N/A
p.
Do you use person protective equipment (PPE) when bathing patients?
1
2
3
4
5
q. If yes, please specify type of PPE: ________________________________________________________________
D. Your Health
19. a.
b.
c.
e.
17. Do you have paid “Sick Leave”?
ÿ Yes
N/A
ÿ No
18. Did you receive prophylaxis for group A streptococcal infection? ÿ Yes ÿ No When? ___ / ___ / ___
ÿ Yes
Since Thanksgiving, have you had a sore throat?
When? ______ / _______ / _______
ÿ No
(If no, skip to #20)
Was a throat swab for testing collected from you?
ÿ Yes
ÿ No d. If yes, specify month: _________________
Was a rapid strep throat test done (you would have been given results immediately)?
f. If yes, specify month: _________________
g. If yes, was the result positive?
ÿ Yes
ÿ No
h.
Were you diagnosed with strep throat?
ÿ Yes
ÿ No
i. If yes, specify month: _________________
j.
l.
Did you miss work for this illness?
How many days were you ill? _____________
ÿ Yes
ÿ No
k. How many days did you miss? ____________
ÿ Yes
ÿ No
n. If yes, antibiotic name ___________________
m. Did you receive antibiotics for this condition?
20.
ÿ Yes
a. Since Thanksgiving, did you have a rash, open wound, or skin infection? ÿ Yes ÿ No (If no, skip to #21)
b. When? ______ / _______ / _______ c. What was your diagnosis? ____________________________
d. Did you miss work for this illness?
f. How many days were you ill? _____________
ÿ Yes
ÿ No
How many days did you miss? ____________
g. Did you receive antibiotics for this condition?
ÿ Yes
ÿ No
If yes, antibiotic name __________________
Study ID #: _CHÿÿÿ
Appendix 1. Invasive GAS in Long Term Care Facility 2016
Employee Survey
21.
a. Since Thanksgiving, did you have fever, cough, and/or other respiratory infection? ÿ Yes
b. When? ______ / _______ / _______
Form Approved; OMB No. 0920-1011
Exp. Date 03/31/2017
ÿ No (If no, skip to #22))
ÿ Yes
ÿ No
How many days did you miss? ____________
e. Did you receive antibiotics for this condition?
ÿ Yes
f. What was your diagnosis? ____________________________
ÿ No
If yes, antibiotic name ___________________
c. Did you miss work for this illness?
d. How many days were you ill? _____________
22. If you’re feeling sick before a work shift, how do you notify Warren Barr Gold Coast?
___________________________________________
23.
a. How many people are in your household? __________ (If none, END)
b. How many children under 18 years of age are in your household? _________
ÿ Yes ÿ No
c. Since Thanksgiving, did anyone in your household have a sore throat?
d. When? ______ / _______ / _______
e. Who (relationship)? ______________________
ÿ Yes
e. Was he/she diagnosed with strep throat?
g. Were they treated? ÿ Yes
ÿ No
ÿ No If so, with what? ________________________________
h. During the past 3 months, did anyone in your household have impetigo or cellulitis (skin infections)?
i. When? ______ / _______ / _______
ÿ Yes
ÿ No
END – Thank you!
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)
Study ID #: _CH______
Appendix 2. Investigation of GAS outbreak in an Long Term Care Facility, 2016
Resident Record Abstraction Form
Form Approved; OMB No. OMB No. 0920-1011
Exp. Date 03/31/2017
Person completing form ______________________
Date Completed: ____/____/____
Resident (check one): ÿ Case ÿ Control
If case, indicate disease classification: ☐invasive
☐noninvasive
☐colonized
If CONTROL, date of matched case’s GAS culture: ____/____/____
Date 14 days prior to positive culture of case: ____/____/_____
Why was the culture obtained?
ÿ Screening
ÿ Illness
A. GAS TESTING RESULTS
1. Has the resident had any cultures/tests for GAS from July 17, 2015 to present?
ÿ Yes
#
ÿ No
Date obtained
Site cultured
Culture
If nonsterile site,
obtained for
was culture
Screening
associated with
Result
illness
a.
____/_____/_______
ÿ Blood
ÿ Skin/Wound: __________
ÿ Other __________
ÿ Throat
ÿ Central line/TPN
ÿ Catheter ÿ Diabetic ulcer
ÿ Post-surgical wound ÿ G-
ÿ Yes
ÿ Yes
ÿ Positive
ÿ No
ÿ No
ÿ Negative
ÿ Yes
ÿ Yes
ÿ Positive
ÿ No
ÿ No
ÿ Negative
tube
b.
____/_____/_______
ÿ Blood
ÿ Skin/Wound: __________
ÿ Other __________
ÿ Throat
ÿ Central line/TPN
ÿ Catheter ÿ Diabetic ulcer
ÿ Post-surgical wound ÿ Gtube
1 of 7
Public reporting burden of this collection of information is estimated to average 45 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)
Study ID #: _CH______
Appendix 2. Investigation of GAS outbreak in an Long Term Care Facility, 2016
Resident Record Abstraction Form
c.
____/_____/_______
ÿ Blood
ÿ Skin/Wound: __________
ÿ Other __________
ÿ Throat
ÿ Central line/TPN
ÿ Catheter ÿ Diabetic ulcer
ÿ Post-surgical wound ÿ G-
ÿ Yes
ÿ Yes
ÿ Positive
ÿ No
ÿ No
ÿ Negative
ÿ Yes
ÿ Yes
ÿ Positive
ÿ No
ÿ No
ÿ Negative
ÿ Yes
ÿ Yes
ÿ Positive
ÿ No
ÿ No
ÿ Negative
ÿ Yes
ÿ Yes
ÿ Positive
ÿ No
ÿ No
ÿ Negative
tube
d.
____/_____/_______
ÿ Blood
ÿ Skin/Wound: __________
ÿ Other __________
ÿ Throat
ÿ Central line/TPN
ÿ Catheter ÿ Diabetic ulcer
ÿ Post-surgical wound ÿ Gtube
e.
____/_____/_______
ÿ Blood
ÿ Skin/Wound: __________
ÿ Other __________
ÿ Throat
ÿ Central line/TPN
ÿ Catheter ÿ Diabetic ulcer
ÿ Post-surgical wound ÿ Gtube
f.
____/_____/_______
ÿ Blood
ÿ Skin/Wound: __________
ÿ Other __________
ÿ Throat
ÿ Central line/TPN
ÿ Catheter ÿ Diabetic ulcer
ÿ Post-surgical wound ÿ Gtube
B. RESIDENT BACKGROUND
2. Sex:
ÿ Male
ÿ Female
3. Age: __________
4. Date of birth: ____/____/____
5a. Room history within 14 days prior to GAS culture:
Room # (floor/wing)
Dates in room
Roommate Yes/No
___/___/____ to ___/___/____
___/___/____ to ___/___/____
___/___/____ to ___/___/____
2 of 7
ÿ Yes
ÿ Yes
ÿ Yes
ÿ No
ÿ No
ÿ No
Roommate (dates)
___/___/____ to ___/___/____
___/___/____ to ___/___/____
___/___/____ to ___/___/____
Study ID #: _CH______
Appendix 2. Investigation of GAS outbreak in an Long Term Care Facility, 2016
Resident Record Abstraction Form
___/___/____ to ___/___/____
___/___/____ to ___/___/____
ÿ Yes
ÿ Yes
ÿ No
ÿ No
___/___/____ to ___/___/____
___/___/____ to ___/___/____
___/___/____ to ___/___/____
ÿ Yes
ÿ No
___/___/____ to ___/___/____
5b. Did the resident have a roommate with GAS infection or colonization within 30 days prior to GAS culture?
ÿ Yes
ÿ No
ÿ Unknown
If yes: initials of GAS+ roommate_________
Dates room shared:____/____/_____
5c. Number of visitors the resident had within 14 days prior to GAS culture? ___________
6. Total length of stay at facility (most recent stay only) at time of GAS culture (mark only one):
_____ months and_______days
7a. Is the resident deceased? ÿ Yes
b. If resident died, death was:
ÿ No
If yes, date of death:
____/____/____
ÿ Related to GAS infection ÿ Possibly related to GAS infection
ÿ Not related
ÿ Not applicable
8. Resident’s physicians within 14 days prior to GAS culture?
Physician’s name
Specialty (e.g., wound care, etc.)
C. MEDICAL HISTORY
9. Which medical condition(s) does the resident have? (mark ALL that apply):
ÿ Diabetes
ÿ CHF/history of MI
ÿ Peripheral vascular disease
ÿ Stroke
ÿ Asthma/COPD
ÿ Hypertension
ÿ Chronic leg edema
ÿ Recent herpes zoster
ÿ Dialysis
ÿ Renal insufficiency
ÿ Dementia
╪〩Ｇ
ＤＣ〤糎
Ｈ Ｃ糎
〤ＤＣ〥ＩＤＣ
糎
ÿ Cancer, specify type: _________________
ÿ Immunosuppressed/immunosuppression
ÿ Cirrhosis
ÿ Prosthetic
ÿ Recent IV Drug Use
Malnutrition
3 of 7
ÿ None
ÿ Other: _______________________
Study ID #: _CH______
Appendix 2. Investigation of GAS outbreak in an Long Term Care Facility, 2016
Resident Record Abstraction Form
(Note: immunosuppression includes: HIV/AIDS, chemo, radiation, immunosuppressive meds, including
tacrolimus [Prograf], sirolimus [Rapamune], mycophenolate mofetil [Cellcept], high-dose or chronic steroids
[prednisone, methylprednisone, hydrocortisone, dexamethasone] methotrexate.)
10a. Weight: ____________ lbs or kg (circle unit of measure)
10b. Height: __________
11. Did patient have any surgical wounds, pressure ulcers, or other wounds (defined as skin breakdown) at the time
of admission to the facility?
ÿ Yes
ÿ No
If yes, how many _____
If Yes, size of largest wound: _____________________________ (e.g., largest width in inches or cm)
12. Did patient have any surgical wounds, pressure ulcers, or other wounds within 14 days prior to GAS culture?
ÿ Yes
ÿ No
If yes, please specify site and number of wounds.
ÿ Right/Left upper extremity ____
ÿ Back____
ÿ Perineal___
ÿ Right/Left lower extremity ____
ÿ Abdomen____
ÿ Right/Left Hand ____
ÿ Sacrum____
ÿ Right/Left Foot ____
ÿ Chest____
糎
Other ____________________
13. Did the patient receive Wound Care Team consultation services within 14 days prior to GAS culture?
ÿ Yes
ÿ No
Dates
Initial(s) of doctors or nurses
Team
14. Did the patient receive wound care WITHOUT Wound Care Team consultation within 14 days prior to GAS
culture?
ÿ Yes
ÿ No
ÿ Unkown
15. Products used for wound care (surgical and nonsurgical) within 14 days prior to GAS culture (check all):
ÿ Calcium Alginate
ÿ Medihoney
ÿ Dakins
ÿ Santyl
ÿ Wound vac ÿ None
ÿ Dry Gauze
ÿ Saf-gel
ÿ Foam: type__________
ÿ Sterile Saline
ÿ Antimicrobial cleanser/cream
ÿ Other: _____________________________
4 of 7
ÿ Hibicleanse
ÿ Iodosorb
Study ID #: _CH______
Appendix 2. Investigation of GAS outbreak in an Long Term Care Facility, 2016
Resident Record Abstraction Form
16a. Did resident have a wound vac at any time from July 17, 2015 – current?
b. Date applied? ___/___/______
ÿ Medela
ÿ Pico
ÿ Pressure: _______
Date removed? ___/___/______
ÿ Pico
ÿ Pressure: _______
d. Date applied? ___/___/______
ÿ Medela
ÿ No
Date removed? ___/___/______
c. Date applied? ___/___/______
ÿ Medela
ÿ Yes
Date removed?
ÿ Pico
ÿ Pressure: _______
17. Has the patient had a surgical procedure within 14 days prior to GAS culture?
ÿ Yes
ÿ No
Procedure
Date
Incision Site
______ / _______ / _______
______ / _______ / _______
18. Within 14 days of GAS culture, was the resident diagnosed with:
a. Cellulitis
b. Wound infection
c.
Pharyngitis
d.
e.
f.
g.
h.
Bacteremia
Pneumonia
Joint Infection
Necrotizing fasciitis
Septic Shock
ÿ Yes
ÿ Yes
ÿ Yes
ÿ Yes
ÿ No
ÿ No
ÿ No
ÿ No
Ye s
Ye s
Ye s
Ye s
No
No
No
No
Date of onset ___/___/____
Date of onset ___/___/____
Date of onset ___/___/____
Date of onset ___/___/____
Date of onset ___/___/____
Date of onset ___/___/____
Date of onset ___/___/____
Date of onset ___/___/____
19. Within 14 days of GAS culture, did the resident have any of the following signs or symptoms? (mark ALL that
apply)
Date of onset (dd/mm/yy)
a.
ÿ Fever (≥100.5oF or 38oC)
______ / _______ / _______
b.
ÿ Sore throat
______ / _______ / _______
d.
ÿ Purulent discharge from wound
______ / _______ / _______
Site:
e.
ÿ Wound – warm on touch
______ / _______ / _______
Site:
f.
ÿ Wound – redness
______ / _______ / _______
Site:
5 of 7
Max temp recorded:
Study ID #: _CH______
Appendix 2. Investigation of GAS outbreak in an Long Term Care Facility, 2016
Resident Record Abstraction Form
g.
ÿ Edema at the site
______ / _______ / _______
Site:
h.
ÿ Increased pain at the site
______ / _______ / _______
Site:
i.
ÿ Joint – warm on touch
______ / _______ / _______
Site:
j.
ÿ Joint – redness
______ / _______ / _______
Site:
20. Was the resident hospitalized for GAS-related symptoms between July 17, 2015 to present?
ÿ Yes
ÿ No
ÿUnknown
a. Hospitalization date: ___/___/____
21. What medications was the resident taking within 14 days prior to GAS culture?
Start Date
Finish Date
Indication
Antibiotics
Chemotherapeutics
Steroids
Immunosuppressives
C. RESIDENT BASELINE STATUS
(Can get further information from nursing)
22. Which equipment does the resident use within 14 days prior to GAS culture (mark ALL that apply):
ÿ Tracheostomy
ÿ Nasal cannula
ÿ Oxygen mask
ÿ Chronic Foley
ÿ G or J tube
ÿ Nasogastric tube
ÿ Colostomy/ileostomy
ÿ Temporary Foley
ÿ Dialysis catheter
ÿ PICC line
ÿ Other, specify: ____________________________
23. Within 14 days prior to GAS culture was the resident ambulatory?
ÿ Yes
ÿ No
6 of 7
Study ID #: _CH______
Appendix 2. Investigation of GAS outbreak in an Long Term Care Facility, 2016
Resident Record Abstraction Form
24. Within 14 days prior to GAS culture, was the resident incontinent of: (mark ALL that apply)
ÿ Not Incontinent
ÿ Stool
ÿ Urine
ÿ Urinary catheter
ÿ Colostomy/Ileostomy
ÿ Unknown
25. Did the resident participate in the following within 14 days prior to GAS culture (mark ALL that apply):
a.
b.
c.
d.
ÿ PT/OT
ÿ Speech pathology
ÿ Podiatry
ÿ Other: ____________________
Times in 14 day period: ______
Times in 14 day period: ______
Times in 14 day period: ______
Times in 14 day period: ______
7 of 7
Study ID #: _CHÿÿÿ
Appendix 3. Invasive GAS in Long Term Care Facility 2016
Wound Care Survey
Form Approved; OMB No. 0920-1011
Exp. Date 03/31/2017
A. Employee Background
3. Sex:
ÿ Male
ÿ Female
1. Name:
2. Age:
4. Employed at Facility since: ______/______/______
5. What is your level of professional training on the wound care team? ÿ RN ÿ MD ÿ LPN ÿ LVN ÿ Other___________
6.
a. Have you received training in infection control practices?
ÿ Yes ÿ No ÿ Unknown
b. If yes, when was your most recent training?
ÿ < 1month ÿ 2-6 months ÿ 6-12months ÿ >1year
B. Wound care
7. How many new wound consults do you see per day?
ÿ 0-4
ÿ 5-9
ÿ 10 or more
8. On average, how many patients with wounds do you see per day? ÿ 0-10
9.
ÿ 10-20
ÿ 20-30
ÿ 30 or more
a. When evaluating a new consult or reassessing an old patient, do you perform a full skin examination? ÿ Yes ÿ No
b. If so, how do you report new wounds found on your exam?
ÿ Medical Chart ÿ Report to Nurse ÿ Report to Doctor ÿ Other
10. Is there a standardized risk assessment tool used to document skin breakdown/ pressure ulcer formation (e.g. Braden
Scale) ÿ Yes ÿ No ÿ Unknown
11. How often do you reassess wounds and document wound healing?
ÿ Daily ÿ 3-7 days ÿ 8-14 days ÿ Monthly ÿ Quarterly ÿ Other: _________
12. What types of care do you perform on the wound care team?
ÿ Incision and Drainage ÿ Undressing/Redressing
ÿ Cleaning wound
______________________
ÿ Wound vac care
ÿ Other:
13. Have you ever discovered pieces of foam/cotton gauze present in the wound from previous dressing changes? ÿ Yes ÿ No
ÿ Unknown
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)
Study ID #: _CHÿÿÿ
Appendix 3. Invasive GAS in Long Term Care Facility 2016
Wound Care Survey
14. Have you been specifically trained in the use of negative-pressure wound
therapy?
ÿ Yes ÿ No
C. Negative-pressure wound
therapy
15. If so, when was your most recent training?
ÿ < 1month ÿ 2-6 months ÿ 6-12months ÿ >1year
16. How many residents require negative-pressure wound therapy/wound vac? _________
17. What type of wound vac is used at your facility?______________________________
18. Who is responsible for the original placement and replacement of the wound vac?
ÿ Patient RN
ÿ CNA
ÿ MD
ÿ Only wound care team
ÿ Other
19. Who is allowed to change the wound vac cartridges and settings? (select more than 1 if applicable)?
ÿ Patient RN
ÿ CNA
ÿ MD
ÿ Only wound care team
ÿ Other
20. How often is a patient with a wound vac reassessed?
ÿ Daily
ÿ 2-3xweek
ÿ Weekly
ÿ Monthly
ÿ Other
21. Are their patients per week are found to have full drainage cartridges or fluid backing up into the drainage tubing?
22. If yes, how would this issue be reported?
ÿ Medical Chart ÿ Report to Nurse ÿ Report to Doctor ÿ Other
23. When replacing the wound vac on the same patient, are any of the following re-used?
(select more than 1 if applies)
ÿ foam/gauze
ÿ adhesive dressing
ÿ drainage tubing ÿ other
24. If worsening wound is observed, is the wound vac replaced before a physician consult?
ÿ Yes
ÿ No
ÿ Symptoms specific
25. If symptoms specific please specify what symptoms would prompt you to replace the wound vac before a physician
consult?
26. What symptoms for a “worsening wound” prompts a physician consult?
ÿ change in character of drained fluid ÿ increase in fluid drainage ÿ increasing erythema
ÿ pain ÿ increase in size
Parish___________________ Village ___________________ GPS Coordinates: Lat _______________Long________________ Elevation (m)_____________
No Animal
Sample
ID
Animal ID
(tagged)
Or
Name/Color
(not tagged)
Owner
Age
Species
Gender
C=Cattle M=Male
G=Goats
Sample ID
M=Middle S=Sheep F=Female
Age
Or
Name
I=Infant
A=adult
C=Castrate
Breed
DD ____/MM____/YY__________
Form Approved OMB
No. 0920-1011
Exp. Date 03/31/2017
Current
Health:
Past Year Comments:
· Symptoms
Health:
(Vet)
( O w n e r ) · Abortion/stillbirth history
S=Sick
· location of origin for slaughterhouse
S=Sick
animals)
H=Healthy H=Healthy
A=aborted A=Aborted *Common RVF symptoms: decreased appetite, decreased
milk production, nose/eye discharge, diarrhea, jaundice,
prostration, lymph node swelling
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Public reporting burden of this collection of information is estimated to average 1 minute 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)
Parish___________________ Village ___________________ GPS Coordinates: Lat _______________Long________________ Elevation (m)_____________
No Animal
Sample
ID
Animal ID
(tagged)
Owner
Age
Species
Gender
C=Cattle M=Male
G=Goats
Sample ID
M=Middle S=Sheep F=Female
Or
Age
Or
C=Castrate
Name/Color
A=adult
(not tagged)
Name
I=Infant
Breed
Current
Health
Status:
DD ____/MM____/YY__________
Form Approved OMB
No. 0920-1011
Exp. Date 03/31/2017
Past Year Comments:
· Symptoms
Health
· Abortion/stillbirth history
Status:
( O w n e r ) · location of origin for slaughterhouse
animals)
S=Sick
(Vet)
S=Sick
H=Healthy H=Healthy *Common RVF symptoms: decreased appetite, decreased
A=aborted A=Aborted milk production, nose/eye discharge, diarrhea, jaundice,
prostration, lymph node swelling
Public reporting burden of this collection of information is estimated to average 1 minute 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)
Sample ID ________________
Date ____/____/__________
Human Questionnaire
Participant classification (A/B/C/D)__________________
Team (1/2) _______
Form Approved OMB
No. 0920-1011
Exp. Date 03/31/2017
Site (1/2/3/etc) _________
Form Completed by
Name: _____________________ Position: ________________District: ______________________
Phone Number/email: _____________________________________________________________
Section 1.
Assessment Participant Information
ID Number: _________________ Family Name:________________ English Name _______________Age: _________Gender:
Male
Female
Village/Town: __________________ Parish: _____________________Sub-County: _______________________
District: _________________Nationality: _____________ Marital status:
Married
Single
Widowed
GPS Coordinates: Lat__________________Long _____________________ Elevation_________________________
Section 2.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
Epidemiological Risk Factors and Exposures
Education level: None Primary Secondary Post-Secondary
Unkn
Other (specify)____________________
Farmer
Herdsman
Housewife
Student
Child
Animal Health worker
Butcher
Primary Occupation:
Trader Other (specify) ______________________________________________________________
Yes
No (If CATTLE/SHEEP/GOAT, COMPLETE LIVESTOCK FORM ON LAST PAGE)
Do you own domestic animals
Yes
No
Unkn (If NO/Unkn, skip to #7)
In the past year, have you had contact with domestic animals
If yes, which domestic animals have you had contact with (tick all that apply)
Cattle
Goat
Sheep
Pigs
Poultry
Dogs others specify________________
During milking During grazing
Grooming Caring for sick animals
If yes, which type of contact (tick all that apply)
Slaughtering/skinning/butchering
Preparing or handling raw meat Sleeping near animals others specify________
Yes
No
Unkn
In the past one year, have you drunk raw milk
Yes
No
Unkn
In the past one year, have you eaten raw/uncooked meat
Yes
No
Unkn
In the past one year, have you been involved in handling or preparing meat
Yes
No
Unkn
In the past one year, have you been involved in Fetus/abortus disposal
Yes
No
Unkn
In the past one year, have you assisted livestock(cattle, sheep and goats) to give birth
Yes
No
Unkn
In the past one year, have you been involved in butchering livestock
Yes
No
Unkn (If NO/Unkn, skip to #15)
In the past one year, have you seen wild animals in this village
Monkeys
Bats
Antelopes
Wild pigs
Others (specify)________________
If yes, which ones:
Yes
No
Unkn (If NO/Unkn, skip to #18)
In past one year , have you any contact with wild animals
If yes, which wild animals do you usually get in contact with (tick all that apply)
Bats Monkeys
Wild Pigs
Wild birds
Rodents Antelopes Others specify__________________________
During hunting Accidental
Slaughtering
Other specify________________________
If yes, which type of contact
Yes
No
Unkn, (If NO/Unkn, skip to #21)
In past one year , have you done hunting
If yes, how often do you do hunting_______________________________
Which animals are usually hunted_______________________________
Yes
No
Unk
In past one year, have you had contact with dead wild animals
Yes
No
Unkn
Not applicable (If NO/Unkn/NA, skip to #24)
Do you use PPE when handling animals
Gumboots
Mask
Eye protection Aprons/ovals
Others (specify)_____________
If yes, which ones Gloves
Yes
No
Unk (If NO/Unknown, skip to #26)
Have you eaten wild meat in the past one year
If Yes, which species___________________
Yes
No
Unkn (If NO/Unkn, skip to #28)
Have you traveled outside your home or village/town in the past one year
If yes, specify location and date: _______________________________________________________
Yes
No
Unkn (If NO/Unkn, skip to #31)
Did you ever suffer from undiagnosed fever or illness in the past one year
If Yes, when? Month ____________ Year __________
Yes
No
If yes, did you seek medical attention:
No
Unkn
Did someone you know in the last one year have unexplained fever or diagnosis? Yes
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)
Sample ID ________________
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
Date ____/____/__________
Form Approved OMB
No. 0920-1011
Exp. Date 03/31/2017
Have you had el nino (have you had more rainfall than usual) rains in the last one year?
Yes
No
Unkn
Yes
No
Unkn (If NO/Unkn, skip to #35)
Have you had flooding in this sub-county in past one year?
If yes, which months do you get flooding_______________________________________
Yes
No
Unkn
In the past year, have you seen more mosquitoes than usual in this village?
Yes
No
Unkn
In the past year, have you been bitten by more mosquitoes than usual?
Yes
No
Unkn (If NO/Unkn, skip to #39)
In the past year, have you been using a mosquito net?
If no, why__________________________________________________
Yes
No
Unkn
In past year, have you sprayed animals against external parasites?
Yes
No
Unkn
Have you done indoor spraying against mosquitoes in the last one year?
Yes
No
Unkn
Have you been the forest/bush in the past one year
Knowledge & Attitude Questions
No
Unkn (If NO/Unkn, skip to #44)
Have you heard about Rift Valley Fever Disease? Yes
Radio
community leaders
others, specify____________________________
If yes, from whom: Health worker
Unkn (If NO/Unkn, skip to #46)
Do you know the signs and symptoms of RVF virus disease in humans? Yes No
fever vomiting diarrhea others specify_____________
If yes, what are some signs and symptoms? bleeding
No
Unkn (If NO/Unkn, skip to #48)
Do you know the signs and symptoms of RVF virus disease in animals? Yes
fever
nasal discharge
diarrhea
abortion
If yes, what are some signs and symptoms in animals? bleeding
reduced milk production
prostration
loss of appetite others, specify______________________________
Yes
No
Unkn
Do you know who to contact in case you see a suspect case of RVF disease?
Yes
No
Unkn (If YES, skip to #51)
Do you believe RVF disease really exists?
If no, why____________________________________________________________________________________________
Yes
No
Unkn
Have you heard of any survivor of RVF disease?
Yes
No
Unkn
Would you relate/interact with a survivor of RVF disease
Would you welcome someone back into their community/neighborhood after a neighbor has recovered from RVF?
Yes
No
Unkn (If YES, skip to #55)
fear of stigma from community others specify______________________
If no, why? fear of contracting disease
Yes
No
Unkn (If NO, skip to #58)
Do you know how RVF disease is transmitted?
body contact sick person
through air
through needle pricks
contact with animals
contact with
If yes, how?
contact with body fluids of sick person biting mosquitoes(insects)
others specify________________
dead person
goats
Cattle
Sheep
Poultry
Dogs
If transmission through animals, which ones?
monkeys
bats
antelopes
wild pigs
Others (specify)_____________
How do you think you can protect yourself from acquiring RVF disease?
vaccination
avoiding contact with animals
traditional medicine
avoiding sick people
sleeping in a mosquito net
Unkn
Others (specify)_____________________________________________
How do you think RVF disease can best be healed or treated?
Traditional medicine
Spiritual healing Modern medicine
Herbal medicine
Unkn
Others (specify)_________________
Yes
No
Unk
Do you think you are at risk of contracting RVF virus disease?
If yes/no, why___________________________________________
Thank you for your Time
Section 3.
End of Interview
Specimen Information
Specimen identification number:___________________
Specimen collection date:___/___/______ (DD/MM/YYYY)
Laboratory testing date:___/___/______ (DD/MM/YYYY)
Results/Titer level: IgM _____________ IgG _____________
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)
Sample ID ________________
Date ____/____/__________
Livestock Assessment Form
Section 1.
1)
2)
3)
4)
5)
6)
Herd Demographics
What is your relationship to the livestock?
Owner
Herdsman
Other(specify)_____________
Yes
No
Unkn
Other (specify)________
Did your animals have blood samples collected today?
Herd location at time of survey? Central collection area
Grazing ground
Other, specify _______________
Number of animals currently owned? Cattle________
Sheep______ Goats______ Pigs_______
Poultry _______ Dogs _______ Cats ______
Enclosed
Non-grazing
Other (specify)_______________
What is the herd’s typical grazing pattern? Shared
Yes
No
Unknown
In the past year, has the herd left the village?
If yes, why?
Nomadic grazing
Trade
Gift/dowry
Other (specify)_________________
If yes, to where? ___________________________
If yes, how many months ago?
<1 month
1-3 months
3-6 months
6-12 months
Section 2.
7)
8)
9)
Form Approved OMB
No. 0920-1011
Exp. Date 03/31/2017
Herd Health Status
In the past year, has your cattle had unusual:
·
Abortions?
Yes No
Yes No
·
Stillbirths?
·
Deaths in adults?
Yes No
Yes No
·
Deaths in young?
·
Other health problems?
Yes No
In the past year, has your goats had unusual:
·
Abortions?
Yes No
Yes No
·
Stillbirths?
·
Deaths in adults?
Yes No
Yes No
·
Deaths in young?
·
Other health problems?
Yes No
In the past year, has your sheep had unusual:
·
Abortions?
Yes No
·
Stillbirths?
Yes No
Yes No
·
Deaths in adults?
·
Death in young?
Yes No
Yes No
·
Other health problems?
If yes, how many? ______________
If yes, how many? ______________
If yes, how many? ______________
If yes, how many? ______________
If yes, what? __________________
If yes, how many? ______________
If yes, how many? ______________
If yes, how many? ______________
If yes, how many? ______________
If yes, what? __________________
If yes, how many? ______________
If yes, how many? ______________
If yes, how many? ______________
If yes, how many? ______________
If yes, what? __________________
*Common RVF symptoms: decreased appetite, decreased milk production, nose/eye discharge, diarrhea, jaundice, prostration, lymph node swelling
Section 3.
10) Have your cattle received:
·
Vaccines?
·
Insecticide treatment?
·
Other treatments?
11) Have your goats received:
·
Vaccines?
·
Insecticide treatment?
·
Other treatments?
12) Have your sheep received:
·
Vaccines?
·
Insecticide treatment?
·
Other treatments?
Herd Treatment
Yes
Yes
Yes
No
No
No
If yes, what vaccines? ______________
If yes, how often? _________________
If yes, what treatment? _____________
Yes
Yes
Yes
No
No
No
If yes, what vaccines? ______________
If yes, when? _____________________
If yes, what treatment? _____________
Yes
Yes
Yes
No
No
No
If yes, what vaccines? ______________
If yes, when? _____________________
If yes, what treatment? _____________
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)
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Telephone Interview Form
SECTION A: General exposure and demographics. Circle response.
1.
Did you (your child) visit the Oak Leaf Dairy farm?
Yes
No
(If YES) ► PROCEED TO QUESTION 2
(If NO) ►“Did anyone else in your household go to the farm? IF yes, may we speak to them? Go to
question 2. If No, “Thank you for your time and participation, I have no further questions.”
2. Since your visit to the farm have you been ill (defined as diarrhea (3 or more loose stools
per day), vomiting, or abdominal cramps)?
Yes No
(If NO) ► PROCEED TO QUESTION 3
(If YES) ►“Are there other members of your household that went to the farm and have not been ill
as defined above?”
If yes, “May we ask to interview and proceed to question 3.
If no, “Thank you for your time someone else from the health department may call you
back to ask additional questions about your illness.”
3. Are there others in your household who visited the farm and have also not been ill?
Yes No
If yes, How many family members visited the farm and are not ill? ______
4.
What is your (your child’s) birthdate? ____/____/_____ (mm/dd/yyyy)
5.
What is your (your child’s) gender?
Male Female Prefer not to answer
6.
What is your (your child’s) town of residence? __________________________
SECTION B. Hand-to-mouth habits
“Let’s talk about hand-to-mouth habits”
7. In general, do you (does your child) chew on or bite your (their) fingernails?
Yes
No
Don’t Know
8. In general, do you (does your child), suck your (their) thumb or fingers?
Yes
No
Don’t Know
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)
1
SECTION C. Prior Animal exposure
“Let’s talk about prior animal exposures”
9.
Do you (does your child) live on a property where farm animals such as cattle, sheep, or
goats are kept?
Yes
No
Don’t Know
IF NO, SKIP TO SECTION D
10.
Which of these animals are kept on the property where you live (where your child lives)?
Please answer yes or no.
Cattle
Yes
No
Sheep
Yes
No
Goats
Yes
No
Other
Yes
No
Specify other animals kept on property: _________________________
(If yes) How long have you owned: ________________________ (months)
SECTION D: Oak Leaf Dairy farm visit to tour.
“Let’s talk about your / your child’s visit to the Oak Leaf Dairy farm.”
11.
Did you (your child) visit the farm more than once? Yes No
12.
On what date did you (your child) visit the farm? ____/____/____ (mm/dd/yyyy)
13.
Approximately how much time did you (your child) spend at the farm?
Less than 1 hour Between 1 and 2 hours Between 2 and 3 hours More than 3 hours
14.
(skip if only one visit) On what date did you (your child) visit the farm? ____/____/____
(mm/dd/yyyy)
15.
(skip if only one visit) Approximately how much time did you (your child) spend at the
farm?
Less than 1 hour Between 1 and 2 hours Between 2 and 3 hours More than 3 hours
16.
(skip if only one visit) On what date did you (your child) visit the farm? ____/____/____
(mm/dd/yyyy)
17.
(skip if only one visit) Approximately how much time did you (your child) spend at the
farm?
Less than 1 hour Between 1 and 2 hours Between 2 and 3 hours More than 3 hours
18.
Did you (your child) attend the Goat Keeping 101 class before Open House on March 12th?
Yes No Don’t Know
2
“Now, let’s talk about areas on the farm. In this first section we will discuss is the baby goat
barn.”
19.
Did you (your child) enter the baby goat barn? Yes
IF NO SKIP TO QUESTION 34
20.
Did you (your child) use hand sanitizer BEFORE visiting the baby goat barn?
Yes
No
Don’t Know
21.
Did you (your child) sit on the ground in the baby goat barn?
22.
Did you (your child) touch/pet the adult goats in the baby goat barn? Yes
No
23.
Did you (your child) feed the adult goats in the baby goat barn? Yes No
Don’t Know
24.
Did you (your child) enter a pen with the baby goats?
(If yes) Did you (your child) sit on the ground in the pen?
(If yes) Did you (your child) sit on a hay bale in the pen?
Yes
Yes
Yes
No
No
No
Don’t Know
Don’t Know
Don’t Know
25.
Did you (your child) touch/pet the baby goats?
Yes
No
Don’t Know
26.
Did you (your child) hold/snuggle the baby goats?
Yes
No
Don’t Know
27.
Did you (your child) kiss the baby goats?
Yes
No
Don’t Know
28.
Did the baby goats lick you (your child)?
Yes
No
Don’t Know
29.
Did you (your child) feed the baby goats?
Yes
No
Don’t Know
30.
Did you (your child) touch a railing while at the baby goat barn? Yes
No
Don’t Know
31.
Did you (your child) use your cell phone in the baby goat barn?
Yes
No
N/A
If Yes:
Did you (your child) talk on your phone?
Yes
No
Don’t Know
Did you (your child) text on your phone?
Yes
No
Don’t Know
Did you (your child) take pictures with your phone?
Yes
No
Don’t Know
(If yes) Did you (your child) take pictures with goats?
Yes
No
Don’t Know
Did you (your child) place your phone down (on hay bales/on railings/on floor)?
Yes No Don’t Know
32.
Did you (your child) use hand sanitizer AFTER visiting the baby goat barn?
Yes
No
Don’t Know
Did you (your child) use baby wipes to clean your (their) hands AFTER visiting the baby goat
barn?
Yes No
Don’t Know
33.
No
Don’t Know
Yes
No
Don’t Know
Don’t Know
3
“Now, let’s talk about the adult goat barn.”
34.
35.
36.
37.
38.
39.
40.
41.
42.
Did you (your child) visit the adult goat barn? Yes No Don’t Know
IF NO, SKIP TO QUESTION 43
Did you (your child) use hand sanitizer BEFORE visiting the adult goat barn?
Yes No Don’t Know
Did you (your child) touch/pet the adult goats at the adult goat barn? Yes No Don’t Know
Did you (your child) feed the adult goats at the adult goat barn? Yes No Don’t Know
Did you (your child) touch a railing while at the adult goat barn? Yes No Don’t Know
Did you (your child) sit on a hay bale while at the adult goat barn? Yes No Don’t Know
Did you (your child) use your cell phone while at the adult goat barn? Yes No N/A
If yes:
Did you (your child) talk on your phone?
Yes No Don’t Know
Did you (your child) text on your phone?
Yes No Don’t Know
Did you (your child) take pictures with your phone?
Yes No Don’t Know
If yes, Did you (your child) take pictures with goats?
Did you (your child) place your phone down (on hay bales/on railings/on floor)?
Yes No Don’t Know
Did you (your child) use hand sanitizer AFTER visiting the adult goat barn?
Yes No Don’t Know
Did you (your child) use baby wipes to clean your (their) hands AFTER visiting the adult goat
barn?
Yes
No Don’t Know
“Now, let’s talk about other things you may have done at the farm.”
43.
44.
Did your child have a pacifier at the farm?
Yes No
N/A
If yes, did your child take it into the baby goat barn?
If yes, did your child take it near the adult goat barn?
Yes
Yes
No
No
Don’t Know
Don’t Know
Did your child have a sippy cup at the farm?
Yes No
N/A
If yes, did your child take it into the baby goat barn?
If yes, did your child take it near the adult goat barn?
Yes
Yes
No
No
Don’t Know
Don’t Know
45.
Did you (your child) chew gum while at the farm?
Yes
No
Don’t Know
46.
Did you (your child) eat candy while at the farm?
Yes
No
Don’t Know
47.
Did you bring a stroller on the farm?
If yes, did you bring it in the baby goat barn?
If yes, did you bring it near the adult goat barn?
Yes
Yes
Yes
No
No
No
N/A
Don’t Know
Don’t Know
4
“Now, let’s talk about other animal contact you may have had at the farm.”
48.
Did you (your child) use hand sanitizer BEFORE touching any animals besides goats?
Yes No
Don’t Know
49.
Did you (your child) touch/pet the rabbits?
Yes
No
Don’t Know
50.
Did you (your child) touch/pet the dogs?
Yes
No
Don’t Know
51.
Did you (your child) use hand sanitizer AFTER touching any animals besides goats?
Yes No
Don’t Know
52.
Did you (your child) use baby wipes to clean your (their) hands AFTER touching any animals
besides goats?
Yes No
Don’t Know
“Now I’m going to ask you some questions about eating and drinking at the farm.”
53.
Did you (your child) eat any food products you may have purchased while at the farm?
Yes No
Don’t Know
(IF NO SKIP TO QUESTION 58)
If yes, did you (your child) use hand sanitizer BEFORE eating?
Yes No
Don’t Know
54.
Did you (your child) eat cheese bought from the farm while at the farm?
Yes No
Don’t Know
If yes, where did you (your child) eat the cheese bought from the farm (circle all that
apply)?
Farm store
Picnic table
Adult goat barn
Baby goat barn
Milking parlor Other
Don’t Know
Did you (your child) drink milk (pasteurized) bought from the farm while at the farm?
Yes No
Don’t Know
If yes, where did you (your child) drink milk (pasteurized) bought from the farm (circle all
that apply)?
Farm store
Picnic table
Adult goat barn
Baby goat barn
Milking parlor Other
Don’t Know
Did you (your child) drink raw milk (unpasteurized) bought from the farm while at the
farm?
Yes No
Don’t Know
If yes, where did you (your child) drink raw milk (unpasteurized) bought from the farm
(circle all that apply)?
Farm store
Picnic table
Adult goat barn
Baby goat barn
Milking parlor Other
Don’t Know
55.
56.
5
57.
Did you (your child) eat caramels bought from the farm while at the farm?
Yes No
Don’t Know
If yes, where did you (your child) eat caramels bought from the farm (circle all that apply)?
Farm store
Picnic table
Adult goat barn
Baby goat barn
Milking parlor Other
Don’t Know
58.
►Did you (your child) taste any samples at farm? Yes No
Don’t Know
(IF NO SKIP TO QUESTION 63)
Did you (your child) use hand sanitizer BEFORE tasting the sample?
Yes No
Don’t Know
59.
Did you (your child) taste cheese samples from the farm while at the farm?
Yes No
Don’t Know
If yes, where did you (your child) eat the cheese sample from the farm (circle all that
apply)?
Farm store
Picnic table
Adult goat barn
Baby goat barn
Milking parlor Other
Don’t Know
Did you (your child) drink milk (pasteurized) samples from the farm while at the farm?
Yes No
Don’t Know
If yes, where did you (your child) drink milk (pasteurized) sample from the farm (circle all
that apply)?
Farm store
Picnic table
Adult goat barn
Baby goat barn
Milking parlor Other
Don’t Know
Did you (your child) drink raw milk (unpasteurized) sample from the farm while at the
farm?
Yes No
Don’t Know
If yes, where did you (your child) drink raw milk (unpasteurized) sample from the farm
(circle all that apply)?
Farm store
Picnic table
Adult goat barn
Baby goat barn
Milking parlor Other
Don’t Know
Did you (your child) eat caramels samples from the farm while at the farm?
Yes No
Don’t Know
If yes, where did you (your child) eat caramels samples from the farm (circle all that
apply)?
Farm store
Picnic table
Adult goat barn
Baby goat barn
Milking parlor Other
Don’t Know
60.
61.
62.
63.
►Did you (your child) bring food to the farm and eat it on the farm (for example, to have a
picnic)?
Yes No
Don’t Know
(IF NO SKIP TO QUESTION 64)
Did you (your child) use hand sanitizer BEFORE eating? Yes No
Don’t Know
Where on the farm did you (your child) eat the food (circle all that apply)?
6
Farm store
Milking parlor
Picnic table
Adult goat barn
Other Don’t Know
Baby goat barn
64.
Did you (your child) drink any beverages that you brought with you at the farm?
Yes No
Don’t Know
(IF NO SKIP TO QUESTION 65)
Where on the farm did you (your child) drink it (circle all that apply)?
Farm store
Picnic table
Adult goat barn
Baby goat barn
Milking parlor
Other Don’t Know
65.
Did you (your child) drink any water from a faucet at the farm? Yes No
Don’t Know
“Now I’m going to ask you some questions about activities after leaving the farm.”
66.
After visiting the farm, did you (your child) stop to eat?
Yes No
If yes, did you (your child) wash your hands before eating? Yes No
If yes, did you (your child) use hand sanitizer before eating? Yes No
Don’t Know
Don’t Know
Don’t Know
67.
After visiting the farm, did you (your child) come home with any of the following?
Dirty or stained clothing?
Yes No
Don’t Know
Dirty shoes?
Yes No
Don’t Know
68.
69.
Did you (your child) remove shoes before walking in the home? Yes No
Don’t Know
Did you (your child) change your clothes immediately when you returned home?
Yes No
Don’t Know
SECTION E: General knowledge and awareness
“Now I would like to ask you some questions about general knowledge on interaction with
animals.”
70.
In general, were you (was your child) aware that some diseases can be spread by having
contact with farm animals?
Yes No
Don’t Know
71.
In general, were you (was your child) aware that some diseases can be spread by having
contact with surfaces at a farm, such as the ground, railings?
Yes No
Don’t Know
SECTION H: Pre-existing medical conditions and medication use
“Now I would like to ask you a few questions about your (your child’s) health in March, 2016. We
would like to know about long-standing medical conditions or other specific medical conditions in
the month of March. You do not need to answer the questions if you don’t want to.”
72.
During the month of March did you (your child) have any of the following medical
conditions?
PLEASE READ EACH CONDITION AND CHECK YES NO DK
7
Yes
Diabetes
Kidney Disease
If YES ► Are you/your child on dialysis?
No
DK
Organ or Bone Marrow Transplant
Leukemia or Cancer
If YES ► Treatment with radiation or chemotherapy in previous
month?
“I would now like to ask some questions about medications that you (your child) may have been
taking in the month of March.”
73.
In the month of March, did you (your child) take any of the following types of medications?
PLEASE READ EACH MEDICATION AND CHECK YES NO DK
Yes
No
DK
Any antibiotics
Any oral steroid, such as Prednisone?
Any immune-suppressing medication, such as to
treat juvenile arthritis?
“Now, I would like to gather some additional information.”
74.
Did you hear or see in the media that the Department of Public Health was requesting ill
and non-ill people that visited the farm to contact them?
Yes
No
75.
What is your (your child’s) race?
White
Black/African American
American Indian/Alaskan Native
Native Hawaiian or Pacific Islander
Asian
Other, specify: ___________________
Unknown
Prefer not to answer
74.
Do you consider yourself (your child) to be of Hispanic ethnicity?
Yes
No
Prefer not to answer
75.
If you (your child) visited the farm more than once, please describe any differences
between your visits:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
8
____________________________________________________________________
9
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Undetermined agent, source, mode of transmission, and risk factors for Guillain-Barré
Syndrome in the setting of Zika virus transmission— Colombia, 2016
Case Control Investigation Form
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)
COL- ____ ____ - ____
Investigation ID Number
□ Case
COL- ____ ____ - ____
□ Control
The ID number begins with the 2 digit case number (for example COL01) followed by an “A” for the case patient, a
“B” for the first control, a “C” for the second control, and a”D” for the third control. For example, the second
control subject matched for case number 8 would be labeled “COL-08-C.”
Interviewer:
___________________________
Neuro Symptom Onset Date for Case
Date of Interview:
__ __ /__ __ /__ __
DD MM YYYY
__ __ /__ __ /__ __
DD MM YYYY
The following questions are to be asked of cases AND controls during the interview:
1. Current Address:
________________________________/__________________/__________________/___________
(Street)
(Town)
(Province)
(District)
2. Onset Address:
_________________________________/__________________/__________________/___________
(for cases only if different from above; where cases spent most nights in the 2 months prior to neuro onset)
3. GPS Coordinates (Onset for cases; current for controls):
4. Sex:
5. Race:
__ __. __ __ __ __ __ S,
__ __ __. __ __ __ __ __ E
□ Male □ Female
□ White □ Brown □ Indigenous □ Black/African decent □ Yellow □ Other:_____________
6. Age when cases developed first neuro symptoms (or equivalent date for controls):
7. What is your occupation?
______ Years
________________________________________________
8. What is the highest level of education you completed?
□ Primary □ Secondary □ Technical □ University □ None
9. Did you travel anywhere two weeks prior to onset of symptoms?
□ Yes
□No
□ Unknown
Where: ______________________________________________
10. Have you ever been told by a clinician that you have any of the following medical conditions?
□ Diabetes
□ Stroke
□ Asthma
□ High blood pressure
□ Kidney disease
□ COPD
□ Heart disease
□ Liver disease
□ Cancer
□ High colesterol
□ Rheumatologic disease
□ Surgery (within 2 months of
symptom onset)
□ Other neurologic illness:______________________________
□ Take any medication or have any condition that might impact your ability to fight infections (e.g.
prednisone):
__________________________________________________
11.
a. In the 2 months prior to __ __ /__ __ /__ __ (neuro onset date for case), have YOU been sick at all?
□ Yes
□No
b. If so, when did you first feel sick?
□ Unknown
__ __ /__ __ /__ __
COL- ____ ____ - ____
c. If so, what symptoms did you have (check all that apply)?
□ Fevers
□ Muscle pains
□ Headache
□ Abdominal pain
□ Pruritus
□ Chills
□ Nausea or Vomiting
□ Diarrhea
□ Joint pains
□ Skin rash
□ Abnormally red eyes
□ Pain behind eyes □ Stiff neck
□ Confusion
□ Coughing □ Runny nose
□ Sore throat
□ Calf pain
d. If so, did you see a doctor or go to the hospital for this illness?
□ Yes □ No □ Unknown
Which doctor? ________________________ Which hospital? _____________________________
e. If so, did they draw any blood for testing?
12.
□ Yes □ No □ Unknown
a. In the 2 months prior to __ __ /__ __ /__ __ (neuro onset date for case), has anyone in your
HOUSEHOLD been sick at all?
□ Yes □ No □ Unknown
b. If so, when did the first household member become sick?
__ __ /__ __ /__ __
c. If so, what symptoms did any household members have (check all that apply)?
□ Fevers
□ Muscle pains
□ Headache
□ Abdominal pain
□ Pruritus
13.
□ Chills
□ Nausea or Vomiting
□ Diarrhea
□ Joint pains
□ Skin rash
□ Abnormally red eyes
□ Pain behind eyes □ Stiff neck
□ Confusion
□ Coughing □ Runny nose
□ Sore throat
□ Calf pain
Which vaccinations have you received and when?
□ Information verified on vaccine card □ Information provided verbally
Vaccine
DD
MM
YYYY
Additional doses
a. MMR
__ __ /__ __ /______
____________
b. Polio
__ __ /__ __ /______
______________
c. Yellow fever
__ __ /__ __ /______
_______________
d. BCG
__ __ /__ __ /______
_______________
e. DPT
__ __ /__ __ /______
_______________
f. HiB
__ __ /__ __ /______
______________
g. Pneumococcal
__ __ /__ __ /______
______________
h. Meningitis
__ __ /__ __ /______
______________
i. Hepatitis B
__ __ /__ __ /______
______________
j. Other vaccines (e.g. rabies, 23-pneumo, Japanese encephalitis, etc.):
__________
_____
__ __ /__ __ /__ __
__________
_____
__ __ /__ __ /__ __
__________
_____
__ __ /__ __ /__ __
COL- ____ ____ - ____
14. In the two months before onset of neurologic symptoms, what pets, farm, or other animals have lived in your
house or on your property (check all that apply)?
□ Dogs
□ Goats
□ Cats
□ Sheep
□ Mice/rats
□ Pet birds
□ Cows
□ Chickens □ Pigs
□ Pet lizards /turtles
□ Other ____________
15. In the two months before onset of neurologic symptoms, how often have you gotten your drinking water from the
tap?
□Almost always (>75%)
□Often (25-75%)
If ever, was the water boiled or treated?
□Yes
□Rarely (<25%)
□Never (0%)
□No
□Unknown
16. In the two months before onset of neurologic symptoms, how often have you gotten your drinking water from a
well or river/stream/pond?
□Almost always (>75%)
□Often (25-75%)
If ever, was the water boiled or treated? □Yes
□Rarely (<25%)
□No
□Never (0%)
□Unknown
17. In the two months before onset of neurologic symptoms, how often do you walk around barefoot outside?
□Almost always (>75%)
□Often (25-75%)
□Rarely (<25%)
□Never (0%)
18. In the two months before onset of neurologic symptoms, have you swam or waded in a freshwater river, stream, or
pond?
□Daily
□Weekly
□Monthly
□Rarely (75%)
□Often (25-75%)
22. Do you normally wear insect repellant?
□Almost always (>75%)
□Often (25-75%)
23. Do you leave the windows open at your house?
□5-8 hours
□>8 hours
□Rarely (<25%)
□Never (0%)
□Rarely (<25%)
□Never (0%)
□Yes, during the day □Yes, at night □Yes, all times
24. How many of your windows or doors have intact screens?
□All of them
□Some of them
□Never
□Windows are not left open at this house
□None of them
25. Does your home use any of the following for air conditioning (check all that apply)?
□Local air conditioning (at least 1 room)
□Fans
□None
26. How often do you have sources of standing water around the outside of your house (e.g. buckets, water
storage/cistern, septic tank, pond)?
□Daily
□2-3 times/week
□Once/week
□Every other week □Never
27. Are these containers covered?
□ Yes □ No □ Unknown
28. In the two months before onset of neurologic symptoms, have you handled any dead animals?
COL- ____ ____ - ____
□Yes
□No
□Unknown
Which? ________________________
29. In 2016, have you eaten or drunk any of the following foods at least once per week (check all that apply)?
□ Beef
□ Milk
□ Lamb
□ Cheese
□
□
Chicken
Yogurt
□ Fish
□ Shellfish
□ Fresh salad / uncooked greens
30. Hughes Disability Score: (Date recorded __ __ /__ __ /__ __)
Hughes Disability Score (0 to 6): _______
□ Unknown
[0 = Complete recovery; no sequelae, 1 = Minor symptoms and capable of running, 2 = Able to walk 10 metres or
more without assistance but unable to run, 3 = Able to walk 10 metres with help, 4 = Bedridden or chairbound
(unable to walk 10 meters with help), 5 = Requiring assisted ventilation for at least part of the day, 6 = Dead]
Formulario Aprobado
OMB No. 0920-1011
Fecha de vencimiento: 03/31/2017
Cuestionario de Caracterización
Síndrome de Guillain-Barré – Colombia, 2016
La carga pública de esta recopilación de información se estima en un promedio de 15 minutos por respuesta, incluyendo el tiempo para revisar las
instrucciones, buscar fuentes de datos existentes, reunir y mantener los datos necesarios y completar y revisar la recopilación de información. Una
agencia no puede realizar o patrocinar ni una persona está obligada a responder a la solicitud de información a menos que se presente un número
de control de OMB válido. Envíe comentarios sobre esta estimación de carga o sobre cualquier otro aspecto de esta recopilación de información,
incluyendo sugerencias para reducir esta carga, al Oficial de Aprobación de Reportes de los CDC/ATSDR; 1600 Clifton Road NE, MS D-74 Atlanta,
Georgia 30333; Atención: PRA (0920-1011)
COL- ____ ____ ____ - ____
Número de Identificación
□ Caso
COL- ____ ____ ____ - ____
□ Control
El número de identificación comienza con los 3 dígitos del número de caso (por ejemplo COL001) seguido por una
“A” para el paciente que sea un caso, una “B” para el primer control, una “C” para el segundo control.. Por
ejemplo, el segundo individuo control emparejado con el caso número 8 sería marcado como “COL-008-C”.
Entrevistador: ___________________________
Fecha de Inicio de Síntomas Neurológicos:
Fecha de Entrevista:
__ __ /__ __ /______
DD MM AAAA
__ __ /__ __ /______
DD MM AAAA
Las siguientes preguntas son para ser realizadas durante la entrevista:
1. Dirección actual:
________________________________________________/____________________/___________________
Dirección
Ciudad o Municipio Distrito o Departamento
2. Dirección donde se presentaron los síntomas:
_________________________________/__________________/__________________/___________
(solamente si es diferente de la dirección actual; donde los casos pasaron el mayor número de noches en los
dos meses previos al inicio del cuadro neurológico)
3. Coordenadas GPS (Inicio de síntomas): __ __. __ __ __ __ __ N,
__ __. __ __ __ __ __ O
□ Masculino
□ Femenino
Pertenencia étinica: □ Indígena □ ROM/Gitano □ Raizal □ Palenquero
□ Negro/mulato/Afrocolombiano
□ Otro
4. Sexo:
5.
6. Edad cuando presentó los primeros síntomas neurológicos: ______ años
7. ¿Cuál es su ocupación? _________________________________________________________________
8. Cuál es su nivel educativo (marque si fue cursado completo):
□ Técnica
□ Universitaria
□ Ninguno
□ Primaria
□ Secundaria
9. Dos semanas antes del inicio de los síntomas neurológicos viajó a otro lugar?
□ Sí □No
□ No sabe
A dónde: ______________________________________________________________________
10. ¿Ha sido informado por algún médico que usted padece alguna de las siguientes condiciones médicas?
□ Diabetes □ Presión Arterial Alta
□ Enfermedad del Corazón □ Colesterol Elevado
□ Accidente Cerebrovascular (Derrame cerebral)
□ Enfermedad Renal □ Enfermedad Hepática
□ Enfermedad Reumatológica
□ Asma
□ Enfermedad Obstructiva Pulmonar Crónica □ Cáncer
□ Cirugía (dentro de los meses de inicio de síntomas)
□ Otra enfermedad neurológica: ______________________________
COL- ____ ____ ____ - ____
□ Toma algún medicamento o ha tenido alguna condición que pueda afectar su capacidad para defenserse las
infecciones (por ejemplo: prednisona) __________________________________________________
11. a. ¿En los dos meses anteriores a __ __ /__ __ /____ (fecha de inicio de cuadro neurológico), estuvo
enfermo (a)?
DD MM AAAA
□ Sí □No
□ No sabe
b. Si estuvo enfermo (a), ¿cuándo se sintió enfermo(a) por primera vez? __ __ /__ __ /_____
DD MM AAAA
c. Si estuvo enfermo (a) ¿Qué síntomas tuvo? (Marque todos los que aplican)
□ Fiebre
□ Dolor muscular
□ Dolor de cabeza
□ Dolor abdominal
□ Escalofrío
□ Nausea o Vómito
□ Dolor articular
□ Rash cutáneo
□ Dolor retro ocular □ Rigidez nucal
□ Tos
□ Secreción nasal □ Odinofagia
□ Diarrea
□ Ojos anormalmente rojos
□ Confusión
□ Dolor de pantorrillas
d. Si estuvo enfermo (a), ¿vió a algún médico o fue al hospital por esta enfermedad?
□ Sí □ No □ No sabe
¿Cuál médico? ________________________ ¿Qué hospital?
e. Si estuvo enfermo (a), ¿le tomaron muestra de sangre?
□ Sí
_____________________________
□ No □ No sabe
12. a. En los dos meses anteriores a __ __ /__ __ /_____ (fecha de inicio de síntomas neurológicos), ¿hubo
DD MM AAAA
alguien en su hogar que haya estado enfermo (a)?
□ Sí □ No □ No sabe
b. Si la respuesta es afirmativa, ¿en qué fecha se enfermó la primera persona de su hogar?
__ __ /__ __ /_____
DD MM AAAA
c. Si alguien en su hogar estuvo enfermo (a) ¿Qué síntomas tuvo? (Marque todos los que aplican)
□ Fiebre
□ Dolor muscular
□ Dolor de cabeza
□ Dolor abdominal
□ Escalofrío
□ Nausea o Vómito
□ Dolor articular
□ Rash cutáneo
□ Dolor retro ocular □ Rigidez nucal
□ Tos
□ Secreción nasal □ Odinofagia
□ Diarrea
□ Ojos anormalmente rojos
□ Confusión
□ Dolor de pantorrillas
13. ¿Qué vacunas ha recibido y cuándo?
□ Información verificada en el carné de vacunas □ Información proveída verbalmente
a. Triple viral (SRP o MMR)
b. Polio
c. Fiebre Amarilla
DD MM AAAA
__ __/__ __/______ Dosis adicionales: ____________________
__ __/__ __/______
____________________
__ __/__ __/______
____________________
COL- ____ ____ ____ - ____
d. BCG
__ __/__ __/______
____________________
e. DPT
__ __/__ __/______
____________________
f. Haemophilus Influenza B
__ __/__ __/______
____________________
g. Neumococo
__ __/__ __/______
____________________
h. Meningitis
__ __/__ __/______
____________________
i. Hepatitis B
__ __/__ __/______
____________________
j. Otras vacunas (ejemplo: rabia, encefalitis Japonesa, etc.):
¿Cuál? ________________________________
__ __/__ __/______
14. En los dos meses antes del inicio de los síntomas neurológicos, ¿qué mascotas, animales de granja u otros
animales vivieron en su casa o su propiedad? (Marque todos los que apliquen)
□ Perros
□ Gatos
□ Ratones/ratas
□ Pájaros domésticos
□ Lagartijas /tortugas □ Cabras □ Ovejas □ Vacas
□ Gallinas
□ Cerdos □ Otros ______________________________________________________________
15. En los dos meses antes del inicio de los síntomas neurológicos, ¿qué tan frecuentemente tomó agua que no
estaba hervida o tratada?
□Casi siempre (>75%)
□A veces (25-75%)
□Rara vez (<25%)
□Nunca (0%)
16. En los dos meses antes del inicio de los síntomas neurológicos, ¿qué tan a menudo tomó agua de un pozo, rio,
quebrada o lago?
□Casi siempre (>75%) □A veces (25-75%)
Si tomó alguna vez, ¿hirvieron o trataron el agua?
□Rara vez (<25%)
□Sí
□No
□Nunca (0%)
□No sabe
17. En los dos meses antes del inicio de los síntomas neurológicos, ¿qué tan a menudo salió de su casa a caminar
descalzo(a)?
□Casi siempre (>75%) □A veces (25-75%)
□Rara vez (<25%)
□Nunca (0%)
18. En los dos meses antes del inicio de los síntomas neurológicos, ¿nadó o cruzó por sus propios medios un rio,
arroyo, o lago?
□Diariamente □Semanalmente
□Nunca
□Mensualmente
19. ¿Cuántas horas al día está al aire libre?
□Menos de 1 hora
□1-4 hora
□5-8 horas
□Rara vez (menos de una vez al mes)
□>8 horas
20. Qué tan frecuente es el uso de ropa con mangas y pantalón largos?
□Casi siempre (>75%) □A menudo (25-75%)
21. ¿Usa repelente de insectos?
□Casi siempre (>75%) □A menudo (25-75%)
22. ¿Fumiga dentro su vivienda?
□Casi siempre (>75%) □A menudo (25-75%)
□Rara vez (<25%)
□Nunca (0%)
□Rara vez (<25%)
□Nunca (0%)
□Rara vez (<25%)
□Nunca (0%)
COL- ____ ____ ____ - ____
23. ¿Deja las ventanas de su casa abiertas?
□Sí, durante el día
□Sí, en la noche
□Sí, todo el tiempo
□Las ventanas no se dejan abiertas en
esta casa
24. ¿Cuántas de sus ventanas o puertas tienen angeos intactos?
□Todas
□Algunas de ellas □Ninguna
25. ¿Tienen en su casa alguno de los siguientes tipos de aire acondicionado?
□Aire acondicionado central
□Aire acondicionado por habitación
□Ninguno
26. ¿Qué tan a menudo tiene recipientes alrededor de su casa donde puede haber agua estancada? (por
ejemplo: baldes, cisternas, tanques, inservibles)
□Diariamente
□2-3 veces/semana
□Una vez a la semana
□Semana de por medio □Nunca
27. Estos recipientes se encuentran tapados
□Sí
□No □No sabe
28. En los dos meses antes del inicio de los síntomas neurológicos, ¿ha manipulado algún animal
muerto?
□Sí
□No □No sabe
¿Cuál? __________________________________________________________________
29. En el año 2016, ¿ha consumido alguno de los siguientes alimentos o bebidas por lo menos una vez a la
semana? (Marque todos los que apliquen)
a.
b.
□ Carne
□ Leche
□ Cordero
□ Queso
□
□
Pollo
Yogurt
□ Pescado □ Mariscos
□ Ensalada / verduras crudas
30. Puntaje de Discapacidad de Hughes: (Fecha de registro: __ __ /__ __ /_____)
Puntaje de Discapacidad de Hughes (0 a 6): _______
□ Desconocido
[0= Recuperación completa; sin secuelas, 1= Síntomas menores y capaz de correr, 2= Puede
caminar 10 metros o más sin asistencia pero no puede correr, 3=Puede caminar 10 metros con
ayuda, 4= Postrado en cama o en silla de ruedas (no puede caminar 10 metros con ayuda), 5=
Requiere ventilación asistida por lo menos una parte del día, 6=Muerto]
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Undetermined agent, source, mode of transmission, and risk factors for Guillain-Barré
Syndrome in the setting of Zika virus transmission— Colombia, 2016
Chart Abstraction Form
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)
Study ID Number
COL-____ ____
Encounter level (Brighton 1-5) or not neuro (6): ____
The ID number begins with the 2 digit case number (for example COL-01). Information as documented by attending
physician.
The following pages are to be abstracted from the medical records / exam:
Chart Abstractor:
MRN:
____________________________
____________________________
1. First name: _______________________________
2. Paternal name: ____________________________
3. Age (years): ______________________________
4. Sex:
□ Male
Abstraction Date: __ __ /__ __ /________
MM DD YYYY
Middle name: ______________________________
Maternal name: _____________________________
Date of birth: __ __ /__ __ /________
MM DD YYYY
□Female
5. Patient address: ___________________________________________________________________________
6. Patient phone number: ______________________
7. Date of neuro symptom onset: __ __ /__ __ /________ Date first sought care: __ __ /__ __ /________
MM DD YYYY
MM DD YYYY
Date of admission: __ __ /__ __ /________
MM DD YYYY
Date of discharge/death: __ __ /__ __ /________
MM DD YYYY
8. Discharged to:
□ Home □ Rehab/skilled nursing facility □ Transferred □ Died □ Other (specify) _____________
CURRENT ILLNESS
9. How long from onset until hospital admission? __________minutes/hours/days/weeks
10. What were the initial neurologic symptoms (i.e. within the three days of illness onset)? (check all that apply, signs
from PE, symptoms from HPI)
□ Leg weakness
□ Leg numbness/paresthesias
□ SOB / respiratory distress
□ Hyporeflexia/areflexia
□ Arm weakness
□ Diplopia/Ophthalmoplegia
□ Arm numbness/paresthesias
□ Face numbness/paresthesias
□ Gait imbalance (not weakness)/ataxia
□ Hand clumsiness/ataxia
□ Face weakness □ Dysarthria □ Dysphagia
□ Dysautonomia
11. What neurologic symptoms occurred AT ANY TIME during the neuro illness? (check all that apply, signs from
PE, symptoms from HPI)
□ Leg weakness
□ Arm weakness
□ Leg numbness/paresthesias □ Arm numbness/paresthesias
□ Diplopia/Ophthalmoplegia
□ Face numbness/paresthesias
2
Study ID Number
COL-____ ____
Encounter level (Brighton 1-5) or not neuro (6): ____
□ SOB / respiratory distress □ Gait imbalance (not weakness)/ataxia
□ Hand clumsiness/ataxia
□ Hyporeflexia/areflexia
□ Face weakness □ Dysarthria □ Dysphagia
□ Dysautonomia
12. How long from onset until maximum/worst neuro symptoms? ____________ minutes/hours/days/weeks
13. At the worst point during this neuro illness, check all that apply for the patient:
□ Unable to walk without assistance (e.g. cane, walker)
□ Admitted to the hospital
□ Admitted to the ICU/CCU
□ Unable to walk at all
□ Intubated
14. If any blood was taken for this neurologic illness, please fill out the following for the INITIAL blood draw:
Date __ __ /__ __ /_______
MM DD YYYY
WBC ____
HgB____
Plts _____
Na ____
K____
BUN ____
Glucose____
TBili____
AST ____
ALT____
AlkPhos ___
Cr ______
□ Yes
15. Was there documented hyporeflexia/areflexia?
□ No
□ Unknown
16. a. Was there documentation of upper motor neuron signs?
□ Yes
□ No
□ Unknown
b. If yes, which:
□ Hyperreflexia
□ Increased tone/spasticity
□
Babinski/Hoffman
□ Yes
17. Was there any sensory level documented?
□ No
□ Sustained clonus
□ Unknown
LABORATORY, IMAGING, AND ELECTROPHYSIOLOGIC STUDIES
18. Was a lumbar puncture (LP) done?
□ Yes
□ No
□ Unknown
LP date ___/____/____ RBCS _______ WBCS ______ Protein (mg/dL)______ Glucose (mg/dL) _______
MM DD YYYY
Differential________________________IgG index______ Oligoclonal bands______ IgG synthesis___________
LP date ___/____/____ RBCS _______ WBCS ______ Protein (mg/dL)______ Glucose (mg/dL) _______
MM DD YYYY
Differential________________________IgG index______ Oligoclonal bands______ IgG synthesis___________
19. Did they receive any targeted treatment (IVIG/steroids/plasma exchange) for this neuro illness?
IVIG
□ Yes □ No □ Unknown
Start date
Plasma exchange
□ Yes □ No □ Unknown
__ __ /__ __ /________
MM DD YYYY
Start date
__ __ /__ __ /________
MM DD YYYY
3
Study ID Number
COL-____ ____
Encounter level (Brighton 1-5) or not neuro (6): ____
Steroids
□ Yes □ No □ Unknown
Start date
Mechanical ventilation
□ Yes □ No □ Unknown
__ __ /__ __ /________
MM DD YYYY
Start date
Other
□ Yes □ No □ Unknown
__ __ /__ __ /________
MM DD YYYY
Start date
__ __ /__ __ /________
MM DD YYYY
20. Did the patient receive blood transfusion/blood products? (other than IVIG)
□ Yes □ No □ Unknown
which one________________
Start date __ __ /__ __ /________
MM DD YYYY
21. Were any of the following diseases tested for? If so, what was the result? (including specimen and type of test)
a. Campylobacter jejuni
b. Mycoplasma pneumoniae
c. Haemophilus influenzae
d. Salmonella spp.
e. Cytomegalovirus (CMV)
f. Epstein-Barr virus (EBV)
g. Varicella-zoster virus (VZV)
h. Human immunodeficiency virus (HIV)
i. Enterovirus / Rhinovirus
j. Arboviruses
k. Other
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
Result:___________________________
Result:___________________________
Result:___________________________
Result:___________________________
Result:___________________________
Result:___________________________
Result:___________________________
Result:___________________________
Result:___________________________
Result:___________________________
Result:___________________________
22. Was neuro imaging done? If so, what was the result? (Transcribe the impression)
□ Yes □ No
Result:_______________________________________________________________________
__________________________________________
Date __ __ /__ __ /________
MM DD YYYY
23. Were electro-diagnostics done (e.g. EMG)? If so, what were the results? (Transcribe the impression)
□ Yes □ No
Result:_______________________________________________________________________
__________________________________________
24. What was the GBS Brighton level?
1
2
3
4
Date __ __ /__ __ /________
MM DD YYYY
5
Levels of Diagnostic Certainty
Level 1
Level 2
Absence of an alternative diagnosis for weakness
Acute onset of bilateral and relatively symmetric flaccid weakness of the limbs
Decreased or absent deep tendon reflexes in affected limbs
Level 3
Level 4*
Level 5
NOT a case
* Lacking
documentation to
4
Study ID Number
COL-____ ____
Encounter level (Brighton 1-5) or not neuro (6): ____
Monophasic illness pattern with weakness nadir between 12 hours and 28 days, followed by clinical
plateau
Albuminocytologic dissociation
CSF with a total white cell count < 50
(elevation of CSF protein level above cells/mm3 (with or without CSF protein
laboratory normal value and CSF
elevation above laboratory normal value) or
total white cell count < 50
if CSF not collected or results not available,
cells/mm3)
and electrodiagnostic studies consistent
with GBS
Electrophysiologic findings
consistent with GBS
fulfill minimal
case criteria
ANTECEDENT ILLNESS
25. a.) In the 2 months prior to neuro onset date, did the individual experience an acute illness? (other than their neuro
illness)?
□ Yes
□No
□ Unknown
b.) How long from prior acute illness onset until admission for neuro illness? _________
minutes/hours/days/weeks
26. a.) What symptoms did they report having or what signs were noticed? (check all that apply)
□ Fevers
□ Muscle pains
□ Headache
□ Back pain
□ Sore throat
□ Chills
□ Joint pains
□ Pain behind eyes
□ Abdominal pain
□ Calf pain
□ Nausea or Vomiting
□ Skin rash
□ Stiff neck
□ Coughing
□ Pruritis
□ Diarrhea
□ Conjunctivitis
□ Confusion
□ Runny nose
b.) If any blood was taken for this acute illness, please fill out the following for the INITIAL blood draw:
Date __ __ /__ __ /________
WBC ____
HgB____
Plts _____
Na ____
K____
DD MM
YYYY
BUN ____
Cr ______
Glucose____ TBili____
AST ____
ALT____
AlkPhos ___
c.) Were they hospitalized for this acute illness?
d.) Did they receive any blood products / IVIG for this illness?
What product? _____________________
Yes
Yes
□ No □ Unknown
□ No □ Unknown
Date? __ __ /__ __ /________
MM DD YYYY
e.) Did they receive plasmapheresis / plasma exchange for this illness?
If yes, date?
□
□
□
Yes
□ No □ Unknown
□
Yes
□ No □ Unknown
□
Yes
□ No □ Unknown
__ __ /__ __ /________
MM DD YYYY
27. Is there a test result available for dengue from this medical visit?
If yes, please specify:_______________________________________
28. Is there a test result available for chikungunya from this medical visit?
If yes, please specify:_______________________________________
5
Study ID Number
COL-____ ____
Encounter level (Brighton 1-5) or not neuro (6): ____
□
29. Is there a test result available for Zika from this medical visit?
Yes
□ No □ Unknown
If yes, please specify:_______________________________________
PAST MEDICAL, SOCIAL AND FAMILY HISTORY
30. What medical conditions are listed in the admission history and physical (H&P)?
□ Hypertension
□ Prior GBS
□ Diabetes
□ HIV
□ Autoimmune disorder____________
□ Hemoglobinopathy □ B12 deficiency □ Cancer _______________________
31. What social conditions are listed in admission H&P?
□ Alcohol use
□ Drug use
□ Tobacco
□ Other ________________________
32. What conditions are listed in family history of H&P?
□ Autoimmune disorder (specify)___________________
□ Hemoglobinopathy (specify) _____________________
□ Cancer (specify) ____________________
□ Neuro (specify) ____________________
6
Formulario Aprobado
OMB No. 0920-1011
Fecha de vencimiento: 03/31/2017
Instrumento para la recolección de datos de historias clínicas.
Caracterización de casos con Síndrome de Guillain-Barré – Colombia, 2016
La carga pública de esta recopilación de información se estima en un promedio de 20 minutos por respuesta, incluyendo el tiempo para revisar las
instrucciones, buscar fuentes de datos existentes, reunir y mantener los datos necesarios y completar y revisar la recopilación de información. Una
agencia no puede realizar o patrocinar ni una persona está obligada a responder a la solicitud de información a menos que se presente un número de
control de OMB válido. Envíe comentarios sobre esta estimación de carga o sobre cualquier otro aspecto de esta recopilación de información,
incluyendo sugerencias para reducir esta carga, al Oficial de Aprobación de Reportes de los CDC/ATSDR; 1600 Clifton Road NE, MS D-74 Atlanta,
Georgia 30333; Atención: PRA (0920-1011)
Número de Identificación
COL-____ ____ ____
Nivel (Brighton 1-5) o no neurológico (6): ____
El número de identificación comienza con los 3 dígitos del número de caso (por ejemplo COL-001). Información según lo
documentado por el médico tratante
Las siguientes páginas son para ser tomadas a partir de las historias clínicas/exámenes:
Revisor de Historia Clínica: ______________________________
Número de Historia Clínica: _________________________
Fecha de revisión: __ __ /__ __ /________
MM DD YYYY
1. Primer Nombre: ____________________________ Segundo Nombre: ________________________________
2. Primer Apellido: ____________________________ Segundo Apellido: ________________________________
3. Edad (años): _______________________________ Fecha de Nacimiento: __ __ /__ __ /________
MM DD YYYY
4. Sexo:
□ Masculino □ Femenino
5. Dirección de residencia del paciente (Incluir dirección completa, ciudad o municipio y departamento):
_______________________________________________________________________________________________
6. Número de teléfono del paciente: ________________________
7. a.) Fecha de ingreso hospitalario: __ __ /__ __ /______
MM DD YYYY
b.) Fecha en la que buscó atención por primera vez: __ __ /__ __ /______
MM DD YYYY
c.) Fecha de egreso hospitalario/muerte: __ __ /__ __ /_______
MM DD YYYY
8. Egresó hacia:
□ Hogar □ Centro de Rehabilitación □ Remitido a otra institución hospitalaria
□ Muerte □ Otro (Especifique) _______________________________________________________________
ENFERMEDAD ACTUAL
9. ¿Cuánto tiempo transcurrió desde el inicio de los síntomas hasta el ingreso al hospital?___minutos/horas/días/semanas
10. ¿Cuáles fueron los síntomas neurológicos iniciales dentro de los tres días previos al inicio de la enfermedad? (Marque
todas las opciones que apliquen, signos del examen físico y síntomas de historia de enfermedad actual)
□ Debilidad en extremidades inferiores □ Debilidad en extremidades superiores □ Diplopia/Oftalmoplejía
□ Adormecimiento de extremidades inferiores/parestesias
□ Adormecimiento de extremidades superiores/parestesias
□ Adormecimiento de la cara/parestesias
□ Dificultad para respirar/distress respiratorio □ Trastornos de la marcha (sin debilidad)/ataxia
2
Número de Identificación
COL-____ ____ ____
Nivel (Brighton 1-5) o no neurológico (6): ____
□ Trastornos de la motricidad manual/ataxia
□ Hiporeflexia/areflexia □ Debilidad en la cara □ Disartria
□
□
Disfagia
Disautonomía
11. ¿Qué síntomas neurológicos ocurrieron en CUALQUIER MOMENTO durante la enfermedad neurológica? (Marque
todas las opciones que apliquen, signos del examen físico y síntomas de historia de enfermedad actual)
□ Debilidad en extremidades inferiores □ Debilidad en extremidades superiores □ Diplopia/Oftalmoplejía
□ Adormecimiento de extremidades inferiores /parestesias
□ Adormecimiento de extremidades superiores /parestesias
□ Adormecimiento de la cara /parestesias
□ Dificultad para respirar / distress respiratorio □ Trastornos de la marcha (sin debilidad)/ataxia
□ Trastornos de la motricidad manual/ataxia
□ Hiporeflexia/areflexia
□ Debilidad en la cara □ Disartria □ Disfagia □ Disautonomía
12. ¿Cuánto tiempo transcurrió desde el inicio hasta la presentación de los síntomas neurológicos más severos?
____ minutos/horas/días/semanas
13. Marque todas las opciones que apliquen al paciente que se presentaron al momento de mayor severidad del cuadro
neurológico:
□ Incapacidad para caminar sin asistencia (por ejemplo: bastón, caminador) □ Incapacidad total para caminar
□ Ingreso al hospital
□ Ingreso a Unidad de Cuidado Intensivo (UCI) □ Intubación
14. Si se extrajo muestra de sangre como parte de los análisis de laboratorio para el cuadro neurológico, por favor
complete las siguiente información de la muestra de sangre obtenida INICIALMENTE:
Fecha __ __ /__ __ /_______
MM DD YYYY
Recuento de blancos __________ Hemoglobina ______ Plaquetas ___________
Sodio ______ Potasio______ BUN ______
AST _______ ALT_______
Creatinina ______ Glucosa _______ Bilirrubina Total______
Fosfatasa Alcalina ________
15. ¿Se documentó hiporeflexia/areflexia?
□ Sí
□ No
□ Desconocido
16. a.) ¿Hubo evidencia de signos de motoneurona superior?
□ Sí
□ No
□ Desconocido
b.) En caso afirmativo, ¿Se documentó algunos de los siguientes hallazgos?
□ Hiperreflexia
□ Aumento en el tono/espasticidad
□
Babinski/Hoffman
□ Clonus sostenido
3
Número de Identificación
COL-____ ____ ____
□ Sí
17. ¿Se documentó algún nivel sensitivo?
□ Guante y Bota
□ Cervical
□ No
□ Dorsal
Nivel (Brighton 1-5) o no neurológico (6): ____
□ Desconocido
□ Lumbar
LABORATORIO, IMÁGENES DIAGNOSTICAS Y ESTUDIOS ELECTROFISIOLÓGICOS
18. ¿Se llevó a cabo una punción lumbar?
□ Sí
□ No
□ Desconocido
Fecha punción lumbar ___/____/______ Recuento de eritrocitos _________ Recuento de leucocitos _________
MM DD YYYY
Proteínas (mg/dL) ______
Glucosa (mg/dL) _______ Diferencial________________________
Gram_________________
Fecha punción lumbar ___/____/______ Recuento de eritrocitos _________ Recuento de leucocitos _________
MM DD YYYY
Proteínas (mg/dL) ______
Glucosa (mg/dL) _______
Diferencial________________________ Gram_________________
19. ¿Recibieron algún tratamiento específico para manejar esta enfermedad neurológica (Inmunoglobulina
intravenosa/esteroides/recambio plasmático)?
a. Inmunoglobulina intravenosa
□ Sí □ No □ Desconocido
b. Recambio plasmático
□ Sí □ No □ Desconocido
c. Esteroides
□ Sí □ No □ Desconocido
d. Ventilación mecánica
□ Sí □ No □ Desconocido
e. Otro
□ Sí □ No □ Desconocido
Fecha de inicio __ __ /__ __ /________
MM DD YYYY
Fecha de inicio __ __ /__ __ /________
MM DD YYYY
Fecha de inicio __ __ /__ __ /________
MM DD YYYY
Fecha de inicio __ __ /__ __ /________
MM DD YYYY
Fecha de inicio __ __ /__ __ /________
MM DD YYYY
20. ¿Recibió el paciente transfusión de sangre o algún otro hemoproducto? (otros diferentes a Inmunoglobulina
intravenosa)
□ Sí □ No □ Desconocido
¿Cuál? _____________
Fecha de inicio __ __ /__ __ /_____
MM
DD
YYYY
21. ¿Fueron algunos de los siguientes patógenos estudiados? En caso afirmativo, ¿cuál fue el resultado? (incluyendo el
espécimen y el tipo de prueba)
a. Campylobacter jejuni
b. Mycoplasma pneumoniae
□ Sí □ No
□ Sí □ No
Resultado: ___________________________
Resultado: ___________________________
4
Número de Identificación
COL-____ ____ ____
c. Haemophilus influenzae
d. Salmonella spp.
e. Citomegalovirus (CMV)
f. Virus Epstein-Barr (EBV)
g. Virus Varicella-zoster (VZV)
h. Virus de Inmunodeficiencia Humana (VIH)
i. Enterovirus / Rhinovirus
j. Arbovirus
k. Otro. ¿Cuál?_________________________
□ Sí
□ Sí
□ Sí
□ Sí
□ Sí
□ Sí
□ Sí
□ Sí
□ Sí
Nivel (Brighton 1-5) o no neurológico (6): ____
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No
Resultado: ___________________________
Resultado: ___________________________
Resultado: ___________________________
Resultado: ___________________________
Resultado: ___________________________
Resultado: ___________________________
Resultado: ___________________________
Resultado: ________________________
Resultado: ___________________________
22. ¿Se llevaron a cabo neuroimágenes diagnósticas?. En caso afirmativo, ¿cuál fue el resultado? (Transcriba el resultado
reportado)
□ Sí □ No
Resultado___________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Fecha __ __ /__ __ /________
MM DD YYYY
23. ¿Se llevaron a cabo pruebas electrodiagnósticas? (por ejemplo: electromiografías). En caso afirmativo, ¿cuál fue el
resultado? (Transcriba el resultado reportado)
□ Sí □ No
Resultado___________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Fecha __ __ /__ __ /________
MM DD YYYY
24. ¿Cuál fue el nivel de SGB en la escala de Brighton? 1
2
3
4
5
Niveles de Certeza Diagnóstica
Nivel 1
Nivel 2
Nivel 3
Ausencia de un diagnóstico alternativo para debilidad
Inicio agudo de debilidad flácida bilitaral y relativamente simétrica de las extremidades
Reflejos tendinosos profundos disminuidos o ausentes en las extremidades afectadas
Patrón de enfermedad monofásica con nadir de debilidad entre 12 horas y 28 días, seguido de
meseta clínica
Nivel 4*
Level 5
NO es un caso
* Al carecer de
documentación
para cumplir con
5
Número de Identificación
COL-____ ____ ____
Disociación albuminocitológica
(elevación del nivel de proteínas en
el LCR por encima del valor
normal de laboratorio y recuento
total de glóbulos blancos en LCR
<50 células / mm3)
Nivel (Brighton 1-5) o no neurológico (6): ____
LCR con un total de recuento de glóbulos
blancos<50 células / mm3 (con o sin
elevación de proteínas en LCR sobre el
valor normal de laboratorio) o si el LCR
no fue recolectado o los resultados no
están disponibles y los estudios de
electrodiagnóstico son consistentes con
SGB
los criterios
mínimos de caso
Hallazgos electrofisiológicos
consistentes con SGB
ANTECEDENTES DE LA ENFERMEDAD
25. a.) ¿En los dos meses anteriores a la fecha de inicio de síntomas neurológicos, tuvo el paciente una enfermedad
aguda? (diferente a su enfermedad neurológica)
Si la respuesta es No o Desconocido, vaya a pregunta 30, sección Antecedentes Clínicos, Sociales y Familiares
□ Sí
□ No
□ Desconocido
b.) ¿Cuánto tiempo se presentó desde el inicio de la enfermedad aguda hasta el ingreso hospitalario por la condición
neurológica? _________ minutos/horas/días/semanas
26. a.) ¿Qué síntomas reportaron haber tenido o qué signos fueron evidenciados? (Marque todas las opciones que
apliquen)
□ Fiebre
□ Dolor muscular
□ Cefalea
□ Dolor de espalda
□ Odinofagia
□ Escalofrío
□ Nausea o Vómito
□ Dolor articular
□ Rash cutáneo
□ Dolor retro ocular □ Rigidez nucal
□ Dolor abdominal □ Tos
□ Dolor de pantorrilla
□ Diarrea
□ Conjuntivitis
□ Confusión
□ Secreción nasal
b.) Si se extrajo muestra de sangre como parte de los análisis de la enfermedad aguda, por favor
complete la siguiente información para la muestra de sangre obtenida INICIALMENTE:
Fecha __ __ /__ __ /_______
MM DD YYYY
Recuento de blancos ________ Hemoglobina_______ Plaquetas ___________
Sodio ____
Potasio____
BUN ____
AST ____
ALT____
Fosfatasa Alcalina _____
Creatinina ______
c.) ¿Hubo hospitalización por esta enfermedad aguda?
Glucosa_____ Bilirrubina Total_____
□ Sí □ No □ Desconocido
d.) ¿Recibió alguna transfusión de cualquier hemoproducto/administración de Inmunoglobulina intravenosa para
esta enfermedad aguda?
□
Sí
□ No □ Desconocido
6
Número de Identificación
COL-____ ____ ____
Nivel (Brighton 1-5) o no neurológico (6): ____
En caso afirmativo, ¿Qué producto?__________________________________
e.) ¿Recibió plasmaféresis / recambio plasmático para esta enfermedad aguda?
Fecha: __ __ /__ __ /________
MM DD YYYY
□ Sí □ No □ Desconocido
En caso afirmativo, ¿qué fecha? __ __ /__ __ /________
MM DD YYYY
□ Sí □ No
Resultado □ Positivo □ Negativo
28. ¿Hay algún resultado de laboratorio para chikungunya en esta visita médica? □ Sí □ No
Resultado □ Positivo □ Negativo
29. ¿Hay algún resultado de laboratorio para zika en esta visita médica?
□ Sí □ No
Resultado □ Positivo □ Negativo
27. ¿Hay algún resultado de laboratorio para dengue en esta visita médica?
□ Desconocido
□ Desconocido
□ Desconocido
□ Desconocido
□ Desconocido
□ Desconocido
ANTECEDENTES CLINICOS, SOCIALES Y FAMILIARES
30. ¿Qué antecedentes clínicos están registrados en la historia clínica de ingreso?
□ Hipertensión
□ Diabetes
□ VIH
□ Trastorno autoimmune. En caso afirmativo, ¿cuál? _______________________________________________
□ SGB previo
□ Hemoglobinopatía □ Deficiencia de Vitamina B12
□ Cancer. En caso afirmativo, ¿cuál? ____________________________________________________________
31. ¿Qué antecedentes sociales están registrados en la historia clínica de ingreso?
□ Uso de alcohol
□ Uso de drogas
□ Tabaquismo
□ Otros. En caso afirmativo, ¿cuáles? ___________________________________________________________
32. ¿Qué antecedentes familiares están registrados en la historia clínica de ingreso?
□ Trastornos autoinmunes (Especifique) _________________________________________________________
□ Cáncer (Especifique) _______________________________________________________________________
□ Hemoglobinopatías (Especifique) _____________________________________________________________
□ Neurológicos (Especifique) __________________________________________________________________
7
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Case Abstraction Form
Demographics
Question
RVCT number
Code
Variable
RVCT
Last Name
Lname
First Name
Fname
Alternate Names/Nicknames/Aliases:
Alias
Date of Birth (MM/DD/YY)
DOB
Age (years)
Age
Gender (1=Male, 2=Female, 3=Other, 99=missing)
Sex
Race/Ethnicity (1=Black, 2=White, 3=Hispanic/Latino, 4=
American Indian/Alaskan Native, 5=Native Hawaiian/Pacific
Islander, 6=Asian, 7=Other, 99=Missing) [Mark all that apply]
Tribe
If American Indian, then specify tribe:
Tribe A residence If lives on Tribe A reservation, specify which
area:
1=northwest of Yuma, 2=southwest of Yuma, 3=south of Yuma
If lives elsewhere, specify
Race
Locating Information, if available:
Addresses:
Tribe
Residence
Other
Phones:
How long at this address?
Be sure to list any other known addresses during last 3 years.
Country of Birth (1=United States, 2=Other [foreign-born],
99=missing)
Birth
If foreign-born, then specify country:
Date of arrival (MM/DD/YY) For patients born outside the
Country
Arrival
Public reporting burden of this collection of information is estimated to average 4 hours 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)
United States,
enter the date of arrival in the United States.
TB Risk Factors
Question
HIV infection (0=No, 1=Yes, 99=Unknown)
Diabetes (0=No, 1=Yes, 99=Unknown)
If diabetic, most recent HbA1C
Code
Variable
HIV
DM
A1C
Chronic Renal Failure (0=No, 1=Yes, 99=Unknown)
ESRD
Immunosuppression other than HIV (e.g. organ transplant,
chemotherapy, medications such as steroids, TNF blockers.
0=No, 1=Yes, 99=Unknown)
Mental illness (0=No, 1=Yes, 99=Unknown) (Axis I diagnosis
not related to substance abuse, e.g. mood disorders,
schizophrenia, anxiety disorders)
Injection drug use-recent
(Within 1 year of TB diagnosis. 0=No, 1=Yes, 99=Unknown)
Injection drug use-ever
(Prior to 1 year of TB diagnosis. 0=No, 1=Yes, 99=Unknown)
Injection drug names
(open ended) list all drugs injected ever
Non-injection drug use-recent
(Within 1 year of TB diagnosis. 0=No, 1=Yes, 99=Unknown)
Non-injection drug use-ever
(Prior to 1 year of TB diagnosis. 0=No, 1=Yes, 99=Unknown)
Non-Injection drug names
(open ended) list all non-injection drugs used ever
Excess alcohol use-recent
(Within 1 year of TB diagnosis. 0=No, 1=Yes, 99=Unknown)
Excess alcohol use-ever
(Prior to 1 year of TB diagnosis. 0=No, 1=Yes, 99=Unknown)
Smoking commercial tobacco regularly (i.e., most days)
for at least 1 year at time of diagnosis (0=No, 1=Yes,
99=Unknown)
Homeless/unstable housing within 1 year of diagnosis?
(0=No, 1=Yes 99=Unknown)
Homeless/unstable housing >1 year before diagnosis?
(0=No, 1=Yes 99=Unknown)
Use of homeless shelter within 1 year of diagnosis? 0=No,
1=Yes 99=Unknown
Use of homeless shelter >1 year before diagnosis? 0=No,
1=Yes 99=Unknown
Shelter names
(open ended) list all homeless shelters used
At least 1 night in correctional/detention facility within 1
Immune
Mental
IDU_rvct
IDU_ever
IDU_list
NIDU_rvct
NIDU_ever
NIDU_list
EtOH_rvct
EtOH_ever
Tobacco
Home1
Home2
Shelter1
Shelter2
Shelter_list
Incarc1
year of diagnosis? (0=No, 1=Yes 99=Unknown)
At least 1 night in correctional/detention facility >1 year
before diagnosis? (0=No, 1=Yes 99=Unknown)
Incarceration facility names
(open ended) list all correctional/detention facilities where
stayed at least 1 night
Residence in long term care facility within 1 year of
diagnosis?
(0=No, 1=Yes 99=Unknown)
Residence in long term care facility>1 year before
diagnosis?
(0=No, 1=Yes 99=Unknown)
If known exposure to TB case, exposure type:
(1=own household, 2=homeless shelter, 3=jail, 4=other
household, 5=bar, 6= hotel, 7=Other: ______________)
Incarc2
Incarc_list
LTCF1
LTCF2
TBexp
ExpOth
List name of site if known:________________________
TB Case Characteristics
Question
How was case recognized or detected?
(1=symptoms, 2=contact investigation, 3=routine TB
screening by healthcare provider, 4=incidental finding by
healthcare provider, 5=other, 99=unknown)
Cough (0=not present 1= present, 99=unknown)
ExpSite
Code
Variable
Caserec
Cough
Fever (0=not present 1= present, 99=unknown)
Fever
Night Sweats (0=not present 1= present, 99=unknown)
Sweats
Weight Loss (0=not present 1= present, 99=unknown)
Weight
Other TB Symptoms (list)
OthSx
Date of first symptom onset (Enter the first date the patient
began experiencing symptoms in the format MM/DD/YY)
Site of disease
(1=pulmonary, 2=extrapulmonary, 3=both pulmonary and
extrapulmonary)
Diagnostic CXR result (1=Negative, 2=Abnormal, possibly
TB, 3=Abnormal, not consistent with TB, 4=Unknown [not
completed or not available])
Diagnostic chest radiograph (CXR) result date (Enter the
date of the patient’s most recent CXR completed as part of
current diagnostic workup leading to patient’s current
diagnosis of TB. MM/DD/YY)
Cavitary disease on CXR? (0=No, 1=Yes, 99=Unknown)
DateSx
Cavitary disease on CT? (0=No, 1=Yes, 99=Unknown)
CavCT
TBSite
CXRrslt
CXRdate
CavCXR
Sputum AFB smear positive disease? (0=No, 1=Yes,
2=Sputum never submitted)
Sputum
Sputum smear converted to negative (0=No, 1=Yes <2
months of treatment, 2=Yes >2 months of treatment,
3=Unknown/NA)
Other site AFB smear positive? (0=No, 1=Yes,
99=Unknown)
Specify Site:__________________
Culture-confirmed disease? (0=No, 1=sputum only,
2=non-sputum specimen, 3=both sputum and non-sputum
specimens, 4=specimens never submitted, 99=Unknown)
If culture confirmed, list GENType
Smearconv
Culture converted to negative (0=No, 1=Yes <2 months of
treatment, 2=Yes >2 months of treatment, 3=Unknown/NA)
Diagnosis date (MM/DD/YY) (the earliest date of the
following: positive smear, positive culture, positive PCR test,
or abnormal chest x-ray/CT scan)
Drug susceptibility based on molecular testing
(1=Pan-susceptible, 2=INH resistance, 3=rifampin
resistance, 4=multiple resistance, including MDR TB,
88=pending, 99=unknown)
Drug susceptibility based on culture
(1=Pan-susceptible, 2=INH resistance, 3=rifampin
resistance, 4=multiple resistance, including MDR TB,
88=pending, 99=unknown)
INH resistance level (highest concentration at which isolate
is resistant)
Cxconv
RIF resistance level (highest concentration at which isolate
is resistant)
RIFR
Specify any other detected resistance
Oth_R
Diagnostic TST result (Enter the patient’s TST result, if
completed as part of the diagnostic workup leading to the
patient’s current diagnosis of TB. 1=negative, 2=positive,
3=positive with conversion [>10mm increase in last 2 years],
4=not done due to prior positive TST, 5=not done for other
reason, 99=result unknown)
Diagnostic TST reading (mm reading)
TST
Diagnostic TST date (MM/DD/YY)
TSTdate
Diagnostic QFT result (Enter the patient’s qualitative QFT
result, if completed as part of the diagnostic workup leading
to the patient’s current diagnosis of TB. 1=negative,
2=positive, 3=indeterminate, 4=not done, 99=unknown)
Diagnostic QFT value (result-nil). (Enter the quantitative
QFT
OthSmear
OthSite
Culture
GENType
Dxdate
Suscept_Mol
Suscept_DST
INHR
TSTmm
QFTvalue
result of the patient’s current QFT result, 99=Unknown.
Leave blank if not performed.)
Diagnostic QFT date (MM/DD/YY)
QFTdate
Diagnostic T.Spot result (Enter the patient’s qualitative
result, if completed as part of the diagnostic workup leading
to the patient’s current diagnosis of TB. 1=negative,
2=positive, 3=indeterminate, 4=borderline, 5=not done,
99=unknown)
Diagnostic T.Spot value (Enter the quantitative result of the
patient’s current result, 99=Unknown. Leave blank if not
performed.)
Diagnostic T.Spot date (MM/DD/YY)
TSpot
Treatment (1=On treatment, 2=Completed full treatment,
3=Completed partial treatment, 4=Died during treatment, 5=
Died before treatment, 6=died after treatment, 7=awaiting
treatment initiation, 8=refused treatment, 99=Unknown)
Start date of initial TB treatment
(Enter the date of antituberculosis medication in the format
MM/DD/YY.)
If applicable, date of change to MDR TB regimen
(Enter the date of antituberculosis medication in the format
MM/DD/YY.)
List MDR TB regimen
TBrx
Date of treatment completion if done (Enter the date of
antituberculosis medication in the format MM/DD/YY.)
History of loss to follow-up or non-compliance during
this TB treatment course (0= No, 1= Yes, 99=Unknown)
If died, then enter date of death (MM/DD/YY)
Rxcomp
If died, then enter cause of death
Deathcause
Previous TB episodes and LTBI history
Question
Prior TB disease? (0=No, 1=Yes, 99=Unknown)
TSpotvalue
TSpotdate
TBRxdate
MDRRxdate
MDRregimen
TBfu
Deathdate
Code
Variable
PrevTB
Year of previous diagnosis (YYYY)
Prevyr
If prior TB, exposure type (1=own household, 2=homeless
shelter, 3=jail, 4=other household, 5=bar, 6= hotel, 7=Other:
______________)
PrevTBexp
If prior TB, drug susceptibility (1=Pan-susceptible, 2=INH
resistance, 3=rifampin resistance, 4=multiple resistance, incl.
MDR TB, 88=pending, 99=unknown)
If prior TB, Genotype (GENType)
PrevTBexp
oth
Prevresist
PrevGENty
pe
PrevTBRx
TB treatment completed (0= No, 1= Yes, 2=In progress,
99=Unknown)
History of loss to follow-up or non-compliance during TB
treatment (0= No, 1= Yes, 99=Unknown)
Previous positive test for LTBI
0= No, 1= Pos TST, 2=Pos IGRA, 99=Unknown)
Previous TST result date (Enter the date of the patient’s most
recent TST before any test conducted as part of current
diagnostic workup leading to patient’s current diagnosis of TB.
MM/DD/YY)
Previous TST result (MM) (Enter the mm reading of the
patient’s previous TST result. 99=Unknown)
Previous TST interpretation (1=Negative, 2=Positive,
3=Unknown)
PrevTBfu
Previous QFT result date (Enter the date of the patient’s most
recent QFT before any a test conducted as part of current
diagnostic workup leading to patient’s current diagnosis of TB.
MM/DD/YY)
Previous QFT result (Enter value [result-nil]. 99= unknown)
PrevQFTdat
e
HxLTBI
PrevTSTdat
e
PrevTSTm
m
PrevTSTrslt
Previous QFT interpretation (1=Negative, 2=Convertor,
3=Unknown)
Diagnostic T.Spot result (Enter the patient’s qualitative result, if
completed as part of the diagnostic workup leading to the
patient’s current diagnosis of TB. 1=negative, 2=positive,
3=indeterminate, 4=not done, 99=unknown)
Diagnostic T.Spot value (Enter the quantitative result of the
patient’s current result, 99=Unknown. Leave blank if not
performed.)
Diagnostic T.Spot date (MM/DD/YY)
Previous chest radiograph (CXR) result date (Enter the date
of the patient’s most recent CXR before any CXR conducted as
part of current diagnostic workup leading to patient’s current
diagnosis of TB. MM/DD/YY)
Previous CXR result (1=Negative, 2=Abnormal, possibly TB,
3=Abnormal, not consistent with TB, 99=Unknown [not
completed or not available])
Initiated treatment for LTBI?
0=offered but refused, 1=never offered by provider, 2=yes,
initiated, 99=unknown
Prior LTBI treatment completed 0= No, 1= Yes,
99=Unknown
Infectious Period Determination
Question
Code
PrevQFTnu
m
PrevQFTrslt
PrevTSpot
PrevTSpotv
alue
PrevTSpotd
ate
DateprevCX
R
PrevCXRrsl
t
LTBIRxStart
HxLTBIRx
Variable
Date of infectious period beginning (format MM/DD/YY)
-For symptomatic patients, start the infectious period 3
months before “Date of symptom onset” recorded on page 2.
-For asymptomatic patients who have sputum smear-positive
or cavitary disease, start the infectious period 3 months
before the “Diagnosis date” recorded on page 2.
-For asymptomatic patients without sputum smear-positive or
cavitary disease, start the infectious period 1 month before
the “Diagnosis date” recorded on page 2
IPopen
Date of infectious period end (format MM/DD/YY)
For patients who are not isolated, the infectious period can
be closed when the following three conditions are met:
1) Treatment with an adequate regimen (based on drug
susceptibility results) for ≥2 weeks, AND
2) The patient shows clinical improvement, AND
3) Three consecutive sputum smears are negative
(which have been obtained at least 8 hours apart)
IPend
For patients who are isolated (e.g. in a hospital) until these
three conditions are met, then use date of isolation as the
end of the infectious period.
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Case Interview Form
Participant Information
Question
Case Last Name
Case First Name
Alternate Names/Nicknames/Aliases:
Response
Age
Date of Birth
If proxy interviewed, name and relationship to case patient:
Variable Name
Lname
Fname
Alias
Age
DOB
Check the database for the patient’s estimated infectious period.
Start of infectious period: ____________________________
End of infectious period: ________________________________
Explain to the patient that you have been asked by the health department to help determine
why there have been more cases of tuberculosis, or TB. Explain that you will be asking a
series of questions to try to identify where the health department might be able to find other
people who have TB, as well as to figure out where the patient might have gotten sick.
Acknowledge that the patient has already participated in many interviews with health care
providers. Reassure the patient that all answers will be kept confidential, and that the purpose
of the interview is to learn information that can help stop the spread of TB and prevent other
people from getting sick (emphasize protection of families). Thank the patient for his or her
time and for speaking with us.
Note that throughout the interview, the period of interest is
2 years before the start of the infectious period to the end of the infectious period.
Ask patient whether they are from the Tribe A Reservation.
If not, ask where patient came from and when he/she came to the area.
Public reporting burden of this collection of information is estimated to average 2 hours 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)
Discuss symptom onset date. Confirm based on chart data.
“We are interested in learning where you could have been exposed to TB in the 2 years
before you got sick with TB. People sick with TB often have a bad cough, or might lose
a lot of weight. TB is spread through the air when a person who is sick coughs or
speaks and does anything that brings up air from the lungs. How do you think that you
got TB?” Mention household exposure (i.e. people you visited or people who visited you).
Attempt to elicit names of sick contacts who might have been source patients. Note when and
where the exposure occurred. Emphasize that these people are not in trouble, and we are not
trying to blame anyone. We are trying to make sure we can find all sick people and treat them.
“TB is commonly spread among people staying in the same household. We’re worried
about people who may have been staying with you or people you may have stayed with
when you were coughing a lot or started feeling sick. I know it might be hard to
remember, but please try your best. During [infectious period], where did you live, and
who was staying with you?” Emphasize protecting family.
Time
period(s)
Last time
visited
Location
People in household
“TB can also be spread to people you spend a lot of time around, even if you don’t stay
in the same household. During [infectious period], could you tell us where you worked,
where you hung out, and who else was usually there?” Emphasize protecting friends and
family. Mention work sites, bars, friends’ homes.
Location
Dates of
first
attendance
Dates of
most recent
attendance
Frequency
of
attendance
Contacts present
Ask patient how else he/she passes time. As examples, you could mention cards, bingo,
video lottery. Record locations and contacts present.
Activity
Location
Dates of
first
attendance
Dates of
most recent
attendance
Contacts present
3
Ask the patient whether he/she visits friends or family or attends social events ON any
of the reservations in the area, or whether friends/family from on a reservation visited
the patient. Ask for location and dates of visit. Record exposed contacts.
Ask the patient whether he/she visits friends or family or attends social events OFF the
reservations in the area, or whether friends/family from off the reservations visited the
patient. Ask for location and dates of visit. Record exposed contacts.
Explain to patient that certain activities make the body less able to fight off a TB
infection, and make a person more likely to become sick.
Ask about the following TB risk factors. Circle response.
Smoking commercial tobacco during the year before diagnosis?
0=None
1=Less than Daily
2=Daily
3=Does not recall or refuses
Smoking traditional tobacco during the year before diagnosis?
0=None
1=Less than Daily
2=Daily
3=Does not recall or refuses
4
If so:
What substance:_____________________
Participates in “sweats” (traditional sweat lodge purification ceremony): Y
N
Location: ______________________
Alcohol use (“drinking”) within 1 year before diagnosis?
0=Never
1=Rarely (1-2 times ever)
2=Occasionally (more than 1 or 2 times, but less than most days or nights)
3=Frequently (most days or nights of the week)
4=Does not recall or refuses
Note the locations where patient drank alcohol? Smoked?
With whom would the patient usually drink? Smoke?
Among the group that the patient drank with/smoked with, did anyone possibly have
TB?
5
Non-injection drug (“taking anything for recreation, e.g. marijuana”)
use within 1 year before diagnosis
0=Never
1=Rarely (1-2 times ever)
2=Occasionally (more than 1 or 2 times, but less than most days or nights)
3=Frequently (most days or nights of the week)
4=Does not recall or refuses
What kinds of drugs were used before diagnosis? Circle all that apply.
Marijuana
Crack or cocaine
Methamphetamine
Heroin
Prescription drugs
Other drugs: ________________________________
Note the locations where non-injection drugs were used:
Drug use with anyone with possible TB?
Injection drug use (“shooting up”) within 1 year before diagnosis
0=Never
1=Rarely (1-2 times ever)
2=Occasionally (more than 1 or 2 times, but less than most days or nights)
3=Frequently (most days or nights of the week)
4=Does not recall or refuses
What kinds of drugs were used before diagnosis? _______________________
Note the locations where injection drugs were used or obtained:
Drug use with anyone with possible TB?
ANY drug use prior to the year before diagnosis
What kinds of drugs were used? _____________________________________
Note the locations where drugs were used or obtained:
Drug use with anyone with possible TB?
6
Does the patient have any other ideas about places where TB might have spread
(i.e., where people were coughing a lot) or people we should contact?
7
Any other contacts not yet discussed:
Name of Contact Where and
How often
(and contact info when had
had
if available)
contact
contact?
(1=daily, 2=few
times/week,
3=weekly or
less, 99=unk)
Activities
Together
Smoked
together?
Drank
together?
Drugs
together?
(0=no,
1=yes,
99=unk)
(0=no,
1=yes,
99=unk)
(0=no,
1=yes,
99=unk)
Comments
9
Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Tuberculosis Contact Screening Form
q Male
q Female
Contact Name:
DOB:
_____/_____/_____
Age:
Current Location:
Contact Exposure History (During the Infectious Period)
Date of Last Exposure:
_____/_____/_____
Contact’s Relationship to Index:
Location of Exposure:
1. How much time did you spend in the same room or house as
the index while he/she was contagious (during the infectious
period)?
2. How much time did you spend in a bar or drug-using location
as the index while he/she was contagious (during the infectious
period)?
Number of days per week:
Number of hours per day:
Number of days per week:
Number of hours per day:
3. How much time did you spend in the same room in the hospital
while he/she was contagious (during the infectious period)?
Number of days per week:
Number of hours per day:
4. If you are a healthcare worker, did you perform any procedures
on the index patient that may have caused them to cough (such
as suctioning, collecting sputum, performing CPR, using a bag
mask, or intubation)
qYes (If Yes, person is automatically a
close contact)
qNo
IF YES, specify type of procedure(s) and date(s)
5. Specify other contact setting and any related details
Ø Based upon the answers above, is this a “close” contact?
A “close” contact is a person who spent ≥4 hours multiple times or spent ≥8 hours
at least one time inside the same room as the index patient (during the infectious
period)?
TB Symptom Screening (Current Symptoms)
qYes
qNo
Start Date and Duration
Instructions: Screen to see if the contact currently has TB symptoms. Consider the contact “symptomatic for TB” if they have:
(1) A cough for ≥2 weeks duration OR
(2) Two “yes” responses to symptoms #2-8 that cannot be explained by another medical condition
1. Have you been coughing for ≥2 weeks?
qYes
qNo
2. Have you been coughing up blood?
qYes
qNo
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)
3. Have you had difficulty breathing?
qYes
qNo
4. Have you had fevers or chills?
qYes
qNo
5. Have you had night sweats?
qYes
qNo
6. Have you been tired or feeling weak
lately?
qYes
qNo
7. Have you lost your appetite?
qYes
qNo
8. Have you had unplanned weight loss?
qYes qNo
qUnknown
(completely soaking your clothes at night)
qYes
If yes, how much?
qNo
Ø Is this contact symptomatic for TB?
If yes, specify symptom start date: ____/____/_____
TB Risk Factor Screening
Notes
Instructions: Screen to see if the contact has risk factors that could increase their risk for progression to active TB disease.
1. Is this contact >50 years old?
qYes
qNo
2. Was this contact <5 years old
during the exposure period?
qYes
qNo
3. Do you have diabetes?
qYes
qNo or Unknown
4. Do you have HIV?
qYes
qNo or Unknown
5. Do you have cancer?
qYes
qNo or Unknown
6. Do you take prednisone every day?
qYes
qNo
7. Do you smoke tobacco?
qYes
qNo
If yes, specify amount/frequency
8. Do you drink alcohol?
9. Do you use any other substances?
qYes
qYes
qNo
qNo
Ø Does this contact have a high-risk condition?
If the contact answers “yes” to questions 1-6 above,
then the contact has a high-risk condition.
Additional Questions
1. Have you ever been diagnosed with active TB disease?
If so, please provide details including treatment if any.
2. Have you ever been diagnosed with latent TB infection?
If so, please provide details including treatment if any.
3. Have you ever known anybody with TB?
If yes, what was/is the nature of your relationship and contact?
What did/does this person do during the day?
How did/does he/she spend his/her time?
Who spent/spends a lot of time with that person?
If yes, include types/routes, frequency,
and locations where substances
acquired and used
qYes
qNo
4. Do you know anybody now who might have TB symptoms?
(e.g., cough ≥2 weeks, fevers, chills, unintended weight loss)
Test Results
Test Results
END QUESTIONS
Date TST
Placed
Date TST Read
MM
TST 1:
Chest X-Ray
CXR Date: _____/_____/_____
TST 2:
CXR Result:
TST Interpretation:
q Negative q Positive
Date of IGRA
q Not Suggestive of TB
q Suggestive of TB
If pos, Conversion? q
IGRA Result
IGRA 1:
Chest X-Ray
CXR Date: _____/_____/_____
IGRA 2:
CXR Result:
IGRA Interpretation:
q Negative q Positive
q Not Suggestive of TB
q Suggestive of TB
If pos, Conversion? q
Rx End Date:
_____/_____/_____
Rx Regimen:
q LTBI
q TB Disease
Treatment
Outcome
Treatment
Rx Start Date:
_____/_____/_____
q Completed LTBI treatment
q Adverse effects of medicine
q Lost to follow-up
q Refused treatment
q Provider decision to stop
q Moved
q Died
q Other (specify):
____________
TB Status
q Not infected (test negative 8 weeks after last exposure)
Interviewer Name: __________________________
Date: _____/_____/_____
q Lost to
follow-up
| File Type | application/pdf |
| Author | frd3 |
| File Modified | 2016-08-15 |
| File Created | 2016-08-15 |