Novel Influenza A Virus Case Screening Form

Form Approved
OMB No. 0920-0004

Novel Influenza A Virus Case Screening Form 
May be used by local health departments for cases under investigation (CUI) for possible human infection with novel influenza A 
viruses (e.g., variant H3N2v, avian H7N9). Please refer to case definitions for novel influenza A viruses for additional guidance. 
Reporting county:
Interviewer name:

Case residence county:
Phone:

Case phone:
Email:

Case name:

Parent/guardian name (for minors):

Date of report: (mm/dd/yyyy):____/____/______

☐New report

☐Update to previous report

Specimen ID:
Unique ID (e.g,. CountyName_###, Clark_001):
Indicate how case was identified
☐Clinician notified health department
☐Unusual lab result
☐Ill traveler identified returning to US
☐Other: ________________________________________________________
Age: ______ ☐Years

☐Months

If Age Unknown: ☐Child

☐Adult

Sex: ☐Male

☐Cough

☐Sore Throat

☐Female

☐Unknown

Date of illness onset

Symptoms: ☐Fever (≥100°F)

(mm/dd/yyyy): ____/____/______

☐Headache ☐Muscle aches ☐Red/draining eyes ☐Other: _____________________

☐Fatigue

☐Vomiting

Was person hospitalized for this illness?
☐Yes ☐No ☐Unknown

Did person die as a result of this illness?
☐Yes ☐No ☐Unknown

If Yes, date of admission: (mm/dd/yyyy):_____/_____/_______

If Yes, date of death: (mm/dd/yyyy):_____/_____/_______

Did person have contact with swine in the 10 days prior
to illness onset? ☐Yes ☐No ☐Unknown

Did person have contact with poultry/birds in the 10 days
prior to illness onset? ☐Yes ☐No ☐Unknown

Contact may be directly touching swine or walking through an area
where swine are present. (If Yes, describe):

Contact may be directly touching poultry/birds or walking through an
area where poultry/birds are present. (If Yes, describe):

Did person travel ≤ 10 days prior to illness to an area where confirmed cases of novel influenza A were reported?
☐Yes ☐No ☐Unknown If Yes, list destination and dates of travel (including date of return to US):
Did person attend an agricultural event (such as a fair or live animal market) ≤ 10 days prior to illness?
☐Yes ☐No ☐Unknown If Yes, list events and dates of attendance:
Did person have contact ≤ 10 days prior to illness with someone who had fever or respiratory illness?
☐Yes ☐No ☐Unknown If Yes, describe relationship and dates of contact:
Was this person tested for influenza? ☐Yes ☐No ☐Unknown
Test type: ☐Rapid antigen ☐RT-PCR ☐Other
Test result: ☐Influenza A ☐Influenza B ☐Influenza A/B (type not distinguished) ☐Negative ☐Other: ______________
Specimen collection date (mm/dd/yyyy): _____/_____/______ Has a specimen been sent to CDC? ☐Yes ☐No
What PPE did healthcare personnel use when caring for patient or obtaining specimens?
☐N95 mask ☐Surgical mask ☐Eye protection ☐Gloves ☐Gown ☐None ☐Unknown
Is this person a contact of another CUI, or probable or confirmed case? ☐Yes ☐No ☐Unknown
If Yes, Unique ID of the other case and nature of the relationship (e.g., Case is the sister of Clark_002):
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 Information Collection Review Office, 1600 Clifton Road NE, MS D‐74, Atlanta, Georgia 30333; 
ATTN: PRA (0920‐0004).

 For CUIs, arrange for nasopharyngeal (NP) swab collection and RT‐PCR testing at a state public health laboratory.  
 Patients with influenza‐like illness should discuss possible antiviral treatment with a healthcare provider. 
 Healthcare facilities should use appropriate isolation precautions for cases under investigation for infection with novel 
influenza A viruses. Non‐hospitalized cases under investigation should stay home from school, work, and social gatherings 
until fever is gone for at least 24 hours without the use of fever‐reducing medications.  
 If this case is later determined to be a confirmed case of infection with novel influenza A, please notify CDC and complete 
the CDC Human Infection with Novel Influenza A Virus Case Report Form.