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pdf2015-16 FluSurv-NET Influenza Hospitalization
Surveillance Project Case Report Form
U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
ATLANTA, GA 30333
1
Case ID:
5
1
Form Approved
OMB No. 0920-0978
6
A. Patient Data – THIS INFORMATION IS NOT SENT TO CDC
Chart Number:
First Name:
Last Name:
Address:
Census Tract:
Address Type:
(Number, Street, Apt. No.)
(City)
(State)
Phone No.1:
(Zip Code)
Phone No.2:
Emergency Contact 1:
Emergency Contact Phone:
PCP Name 1:
PCP Phone 1:
PCP Fax 1:
PCP Name 2:
PCP Phone 2:
PCP Fax 2:
Site Use 1:
Site Use 2:
Site Use 3:
B. Reporter Information – THIS INFORMATION IS NOT SENT TO CDC
1. Reporter Name:
/
2. Date Reported:
/
C. Enrollment Information
1. Case Classification:
2. Admission Type:
Prospective Surveillance
Discharge Audit
6. Date of Birth:
7. Age:
/
Years
/
3. County:
Hospitalization
8. Sex:
Days
(if < 1 month)
Months
(if < 1 yr)
10. Ethnicity:
Non-Hispanic or Latino
Not Specified
Pediatric
9. Race:
Adult
White
American Indian or Alaska Native
Black or African American
Multiracial
Male
Asian/Pacific Islander
Not specified
12. Was patient transferred from another hospital?
11a. Admission Date:
/
/
12a. Transfer Hospital ID:
11b. Discharge Date:
/
/
12c. Transfer Date:
13. Where did patient reside at the time of hospitalization?
5. Case Type:
Female
11. Hospital ID Where Patient Treated:
Hispanic or Latino
4. State:
Observation Only
12b. Transfer Hospital Admission Date:
/
/
/
Yes
No
Unknown
/
(Indicate TYPE of residence.)
Private residence
Hospitalized at birth
Assisted living/Residential care
Unknown
Homeless/Shelter
Rehabilitation facility
LTACH/Transitional Care (TCU)
Other, specify:
Nursing home
Jail/Prison
Group home/Retirement home
Alcohol/Drug Abuse Treatment
Hospice
Mental Hospital
13a. If resident of a facility, indicate NAME of facility:
D. Influenza Testing Results
1. Test 1:
1a. Result:
Rapid
Molecular Assay
2a. Result:
3a. Result:
4a. Result:
Method Unknown/Note Only
Flu A/B (Not Distinguished)
2009 H1N1
Flu A, Unsubtypable
Flu B, Yamagata
Unknown Type
H1, Unspecified
Flu B (no genotype)
Flu A & B
Negative
Rapid
/
/
Molecular Assay
1c. Testing facility ID:
Viral Culture
Serology
Fluorescent Antibody
Method Unknown/Note Only
H3
Flu B, Victoria
Flu A/B (Not Distinguished)
2009 H1N1
Flu A, Unsubtypable
Flu B, Yamagata
Unknown Type
H1, Unspecified
Flu B (no genotype)
Flu A & B
Negative
Rapid
/
/
Molecular Assay
2c. Testing facility ID:
Viral Culture
Serology
Fluorescent Antibody
Method Unknown/Note Only
H3
Flu B, Victoria
Flu A/B (Not Distinguished)
2009 H1N1
Flu A, Unsubtypable
Flu B, Yamagata
Unknown Type
H1, Unspecified
Flu B (no genotype)
Flu A & B
Negative
/
/
Molecular Assay
3c. Testing facility ID:
Viral Culture
Serology
Method Unknown/Note Only
H3
Flu B, Victoria
Flu A/B (Not Distinguished)
2009 H1N1
Flu A, Unsubtypable
Flu B, Yamagata
Unknown Type
H1, Unspecified
Flu B (no genotype)
Flu A & B
Negative
/
/
Other, specify:
3d. Specimen ID:
Fluorescent Antibody
Flu A (no subtype)
4b. Specimen collection date:
Other, specify:
2d. Specimen ID:
Flu A (no subtype)
Rapid
Other, specify:
1d. Specimen ID:
Flu A (no subtype)
3b. Specimen collection date:
4. Test 4:
Fluorescent Antibody
Flu B, Victoria
2b. Specimen collection date:
3. Test 3:
Serology
H3
1b. Specimen collection date:
2. Test 2:
Viral Culture
Flu A (no subtype)
4c. Testing facility ID:
Other, specify:
4d. Specimen ID:
Public reporting burden of this collection of information is estimated to average 17 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 Request Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0978).
Page 1 of 4
2015-16 FluSurv-NET Influenza Hospitalization
Surveillance Project Case Report Form
1
Case ID:
5
1
6
E. Admission and Patient History
1. Was patient discharged from any hospital within one week prior to the current admission date?
2. Acute signs/symptoms at admission [within 2 weeks prior to positive flu test]:
Yes
No
Unknown
(Write Y or N/Unk next to signs/symptoms)
Altered mental status/confusion
Cough*
Headache
Seizures
Wheezing*
Chest pain
Diarrhea
Myalgia/muscle aches
Shortness of breath/resp distress*
Other, non-respiratory
Congested/runny nose*
Fatigue/weakness
Nausea/vomiting
Sore throat*
Conjunctivitis/pink eye
Fever/chills
Rash
URI/ILI*
/
/
3. Date of onset of acute respiratory symptoms [within 2 weeks prior to positive flu test]:
4. Date of onset of acute condition resulting in current hospitalization:
5. BMI:
6. Height:
Unknown
In
/
/
7. Weight:
Cm
Kg
Yes
10b. Chronic Lung Disease?
Yes
9. Alcohol abuse:
Current
Former
No/Unknown
Unknown
10. Did patient have any of the following pre-existing medical conditions? Check all that apply.
10a. Asthma/Reactive Airway Disease?
Unknown
8. Smoker:
Lbs
Unknown
Unknown
Yes
No
Current
Former
No/Unknown
Unknown
No/Unknown
10h History of Guillain-Barré Syndrome
Yes
No/Unknown
No/Unknown
10i. Immunocompromised Condition
Yes
No/Unknown
Cystic fibrosis
AIDS or CD4 count < 200
Emphysema/COPD
Cancer: current/in treatment or diagnosed in last 12 months
Other, specify:
Complement deficiency
10c. Chronic Metabolic Disease
Yes
HIV Infection
No/Unknown
Diabetes Mellitus
Immunoglobulin deficiency
Thyroid dysfunction
Immunosuppressive therapy
Organ transplant
Other, specify:
10d. Blood disorders/Hemoglobinopathy
Yes
Stem cell transplant (e.g., bone marrow transplant)
No/Unknown
Steroid therapy (taken within 2 weeks of admission)
Sickle cell disease
Other, specify:
Splenectomy/Asplenia
10j. Renal Disease
Thrombocytopenia
Yes
Chronic kidney disease/chronic renal insufficiency
Other, specify:
10e. Cardiovascular Disease
Yes
Atherosclerotic cardiovascular disease (ASCVD)
No/Unknown
End stage renal disease/Dialysis
No/Unknown
Glomerulonephritis
Nephrotic syndrome
Atrial Fibrillation
Other, specify:
Cerebral vascular incident/Stroke
10k. Other
Congenital heart disease
Yes
No/Unknown
Coronary artery disease (CAD)
Intravenous drug use
Heart failure/CHF
Liver disease (e.g., cirrhosis, chronic hepatitis, hepatitis C)
Other, specify:
Systemic lupus erythematosus/SLE/Lupus
Morbidly obese (ADULTS ONLY)
10f. Neuromuscular disorder
Yes
No/Unknown
Obese
Duchenne muscular dystrophy
Pregnant
Muscular dystrophy
If pregnant, specify gestational age in weeks:
Multiple sclerosis
Unknown gestational age
Mitochondrial disorder
Post-partum (two weeks or less)
Myasthenia gravis
Other, specify:
Other, specify:
10g. Neurologic disorder
Yes
No/Unknown
Cerebral palsy
10l. PEDIATRIC CASES ONLY
Cognitive dysfunction
Abnormality of upper airway
History of febrile seizures
Long-term aspirin therapy
Premature
Dementia
Developmental delay
Down syndrome
Yes
No/Unknown
Yes
No/Unknown
Yes
No/Unknown
Yes
(gestation age < 37 weeks at birth for patients < 2yrs)
Plegias/Paralysis
Seizure/Seizure disorder
No/Unknown
If yes, specify gestational age at birth in weeks:
Other, specify:
Unknown gestational age at birth
*These are considered acute respiratory symptoms
F. Intensive Care Unit and Interventions
1. Was the patient admitted to an intensive care unit (ICU)?
1a. Number of ICU admissions:
1b. Date of first ICU Admission:
1c. Date of first ICU Discharge:
Yes
No
Unknown
/
/
/
/
2. Did patient receive mechanical ventilation?
Yes
Unknown
No
Unknown
3. Did patient receive extracorporeal membrane oxygenation
(ECMO or ‘on bypass’)?
Unknown
Unknown
Yes
Page 2 of 4
No
Unknown
2015-16 FluSurv-NET Influenza Hospitalization
Surveillance Project Case Report Form
1
Case ID:
5
1
6
G. Bacterial Pathogens – Sterile or respiratory site only
1. Were any bacterial culture tests performed with a collection date within three days of admission?
Yes
No
Unknown
2. If yes, was there a positive culture for a bacterial pathogen?
Yes
No
Unknown
3a. If yes, specify Pathogen 1:
3c. Site where pathogen identified:
/
3b. Date of culture:
/
Blood
Cerebrospinal fluid (CSF)
Bronchoalveolar lavage (BAL)
Pleural fluid
Sputum
Endotracheal aspirate
Other, specify:
3d. If Staphylococcus aureus, specify:
Methicillin resistant (MRSA)
3f. If Neisseria meningitidis, specify serogroup:
Methicillin sensitive (MSSA)
B
Sensitivity unknown
No
4c. Site where pathogen identified:
/
4b. Date of culture:
/
Blood
Cerebrospinal fluid (CSF)
Bronchoalveolar lavage (BAL)
Pleural fluid
Sputum
Endotracheal aspirate
Other, specify:
4d. If Staphylococcus aureus, specify:
Methicillin resistant (MRSA)
4f. If Neisseria meningitidis, specify serogroup:
Methicillin sensitive (MSSA)
B
Sensitivity unknown
C
Y
Other, specify:
4e. If Haemophilus influenzae, specify if type B:
No
Unknown
Unknown
4a. If yes, specify Pathogen 2:
Yes
Y
Other, specify:
3e. If Haemophilus influenzae, specify if type B:
Yes
C
Unknown
Unknown
H. Viral Pathogens
1. Was patient tested for any of the following viral respiratory pathogens within 3 days of admission?
1a. Respiratory syncytial virus/RSV
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1b. Adenovirus
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1c. Parainfluenza 1
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1d. Parainfluenza 2
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1e. Parainfluenza 3
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1f. Parainfluenza 4
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1g. Human metapneumovirus
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1h. Rhinovirus/Enterovirus
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1i. Coronavirus (type):
Yes, positive
Yes, negative
Not tested/Unknown
Date:
Yes
No
/
/
/
/
/
/
/
/
/
Unknown
/
/
/
/
/
/
/
/
/
I. Influenza Treatment
1. Did patient receive antiviral medication treatment for influenza during the course of this illness?
2a. Treatment 1:
Zanamivir (Relenza)
Other, specify:
Amantadine (Symmetrel)
Rimantadine (Flumadine)
Unknown
2b. Method of Administration:
2c. Start Date:
/
Oral
/
Intravenous (IV)
Zanamivir (Relenza)
Amantadine (Symmetrel)
Rimantadine (Flumadine)
/
Oral
/
Intravenous (IV)
Rimantadine (Flumadine)
/
/
Intravenous (IV)
3e. Dose:
3f. Frequency:
Unknown
Inhaled
/
Unknown
4e. Dose:
End Date Unknown
4f. Frequency:
Dose Unknown
Zanamivir (Relenza)
Other, specify:
Amantadine (Symmetrel)
Rimantadine (Flumadine)
Unknown
/
Oral
/
Start Date Unknown
Intravenous (IV)
5d. End Date:
/
Frequency Unknown
Other, specify:
Oseltamivir (Tamiflu)
5b. Method of Administration:
5c. Start Date:
/
4d. End Date:
Frequency Unknown
Unknown
Dose Unknown
Zanamivir (Relenza)
Start Date Unknown
5a. Treatment 4:
/
Amantadine (Symmetrel)
Oral
2f. Frequency:
Unknown
Inhaled
Oseltamivir (Tamiflu)
Unknown
Other, specify:
End Date Unknown
4b. Method of Administration:
4c. Start Date:
/
3d. End Date:
No
Unknown
2e. Dose:
Dose Unknown
Oseltamivir (Tamiflu)
Start Date Unknown
4a. Treatment 3:
Inhaled
/
End Date Unknown
3b. Method of Administration:
3c. Start Date:
/
2d. End Date:
Start Date Unknown
3a. Treatment 2:
Yes
Oseltamivir (Tamiflu)
Inhaled
/
End Date Unknown
Unknown
5e. Dose:
Dose Unknown
6. Additional Treatment Comments:
Page 3 of 4
Frequency Unknown
5f. Frequency:
Frequency Unknown
2015-16 FluSurv-NET Influenza Hospitalization
Surveillance Project Case Report Form
1
Case ID:
5
1
6
J. Chest Radiograph – Based on radiology report only
1. Was a chest x-ray taken within 3 days of admission?
2. Were any of these chest x-rays abnormal?
Yes
No
No
Unknown
2b. For first abnormal chest x-ray, please check all that apply:
Unknown
2a. Date of first abnormal chest x-ray:
/
Yes
/
Report not available
Consolidation
Interstitial infiltrate
Air space density/opacity
Atelectasis
Pleural effusion/empyema
Bronchopneumonia/pneumonia
Cavitation
Lobar infiltrate
Cannot rule out pneumonia
ARDS (acute respiratory distress syndrome)
Other
K. Discharge Summary
1. Did the patient have any of the following diagnoses at discharge? (check all that apply)
Pneumonia
Yes
No
Unknown
Stroke (CVI)
Yes
No
Unknown
Guillain-Barré syndrome
Yes
No
Unknown
Acute myocarditis
Yes
No
Unknown
Acute encephalopathy/ encephalitis
Yes
No
Unknown
Acute respiratory distress syndrome (ARDS)
Yes
No
Unknown
Seizures
Yes
No
Unknown
Bronchiolitis
Yes
No
Unknown
Reye’s syndrome
Yes
No
Unknown
Hemophagocytic syndrome
Yes
No
Unknown
2. What was the outcome
of the patient?
2a. If discharged alive, please indicate to where:
Alive
Deceased
Unknown
Private residence
Rehabilitation Facility
Group home/Retirement home
Homeless/Shelter
Jail/Prison
Mental Hospital
Nursing home
Hospice
Unknown
Alcohol/Drug Abuse Treatment
Assisted living/Residential care
Other, specify:
Home with services
LTACH/Transitional Care (TCU)
3. If patient was pregnant on admission, indicate pregnancy status at discharge:
Still pregnant
No longer pregnant
Unknown
3a. If patient was pregnant on admission but no longer pregnant at discharge, indicate pregnancy outcome at discharge:
Miscarriage
Ill newborn
Newborn died
Healthy newborn
Abortion
Unknown
4. Additional notes regarding discharge:
L. ICD-9 or ICD-10 Discharge Diagnoses – To be recorded in order of appearance
Version:
ICD-9
ICD-10
1.
4.
7.
2.
5.
8.
3.
6.
9.
M. Vaccination History
Specify vaccination status and date(s) by source:
1. Medical Chart:
Yes, full date known
1a. If yes, specify dosage date information: 1)
/
/
1b. If patient < 9 yrs, specify vaccine type:
Injected Vaccine
2.Vaccine Registry:
Yes, full date known
2a. If yes, specify dosage date information: 1)
2b. If patient < 9 yrs, specify vaccine type:
/
/
Injected Vaccine
Injected Vaccine
4. Interview:
Yes, full date known
Proxy
4b. If patient < 9 yrs, specify vaccine type:
/
Injected Vaccine
Date Unknown
Date Unknown
/
Date Unknown
5. If patient < 9 yrs, did patient receive any seasonal influenza vaccine in previous seasons?
No
2) (Pediatrics Only)
/
No
2) (Pediatrics Only)
No
Combination of both
Yes
No
/
Unknown
/
Date Unknown
Not Checked
/
Date Unknown
Unknown type
Unknown
/
Combination of both
2) (Pediatrics Only)
Not Checked
Unknown type
Combination of both
Yes, specific date unknown
Nasal Spray/FluMist
Unknown
Combination of both
Yes, specific date unknown
Nasal Spray/FluMist
No
2) (Pediatrics Only)
Yes, specific date unknown
Nasal Spray/FluMist
3b. If patient < 9 yrs, specify vaccine type:
Patient
Date Unknown
Nasal Spray/FluMist
3. Primary Care Provider /
Yes, full date known
Long-term Care Facility:
3a. If yes, specify dosage date information: 1)
/
/
4a. If yes, specify dosage date information: 1)
Yes, specific date unknown
Not Checked
/
Date Unknown
Unknown type
Unknown
/
Not Checked
/
Date Unknown
Unknown type
Unknown
N. Miscellaneous
1. Additional Comments:
CDC Rev. 07-2015
Page 4 of 4
CS255957
| File Type | application/pdf |
| File Modified | 2015-08-12 |
| File Created | 2015-08-12 |