Adenovirus Typing Report Form

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Overview

REPORT FORM
STATE FIPS CODE LIST

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Sheet 1: REPORT FORM

Adenovirus Typing Report Form

Form OMB No. 0920-0004

Reporting Lab :

Report Date:

Positive Test Results

Age (# Only)

Age Type (Months or Years)

Sex (M/F/U)

State of Residence (see codes--2rd sheet)

AdV Group (A-F)

AdV Type

Source Specimen (see legend--far right)

Specimen Collection Date (mm/dd/yyyy)

Hospitalized (Y/N/U)

Outbreak(Y/N/U)

Specimen Legend

1

NP/OP swab

Outbreak Type

2

NP/OP wash

(see legend--far right)

3

Sputum

4

Tracheal Aspirate

5

Bronchoalveolar Lavage

6

Pleural Fluid

7

Ocular Swab

8

Other

9

Unknown

Outbreak Type

1

Hospital

2

School

3

Daycare

4

Long Term Care Facility

5

Military

8

Other (specify) _______

9

Unknown

Date of Report

Reporting Official

Title

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-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0004).

CDC XXXX Rev.01/2014

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Sheet 2: STATE FIPS CODE LIST

CODE	ABBR	STATENAME
1	AL	ALABAMA
2	AK	ALASKA
4	AZ	ARIZONA
5	AR	ARKANSAS
6	CA	CALIFORNIA
8	CO	COLORADO
9	CT	CONNECTICUT
10	DE	DELAWARE
11	DC	DISTRICT OF COLUMBIA
12	FL	FLORIDA
13	GA	GEORGIA
15	HI	HAWAII
16	ID	IDAHO
17	IL	ILLINOIS
18	IN	INDIANA
19	IA	IOWA
20	KS	KANSAS
21	KY	KENTUCKY
22	LA	LOUISIANA
23	ME	MAINE
24	MD	MARYLAND
25	MA	MASSACHUSETTS
26	MI	MICHIGAN
27	MN	MINNESOTA
28	MS	MISSISSIPPI
29	MO	MISSOURI
30	MT	MONTANA
31	NE	NEBRASKA
32	NV	NEVADA
33	NH	NEW HAMPSHIRE
34	NJ	NEW JERSEY
35	NM	NEW MEXICO
36	NY	NEW YORK
37	NC	NORTH CAROLINA
38	ND	NORTH DAKOTA
39	OH	OHIO
40	OK	OKLAHOMA
41	OR	OREGON
42	PA	PENNSYLVANIA
44	RI	RHODE ISLAND
45	SC	SOUTH CAROLINA
46	SD	SOUTH DAKOTA
47	TN	TENNESSEE
48	TX	TEXAS
49	UT	UTAH
50	VT	VERMONT
51	VA	VIRGINIA
53	WA	WASHINGTON
54	WV	WEST VIRGINIA
55	WI	WISCONSIN
56	WY	WYOMING
60	AS	AMERICAN SAMOA
64	FM	FEDERATED STATES OF MICRONESIA
66	GU	GUAM
69	MP	NORTHERN MARIANA ISLANDS
70	PW	PALAU
72	PR	PUERTO RICO
74	UM	U.S. MINOR OUTLYING ISLANDS
78	VI	VIRGIN ISLANDS
99	UNK	UNKNOWN