Telephonic script to contact Zika virus disease cases to obtain additional clinical information - Hospitalization

Form Approved

OMB Control No. 0920-XXXX

Exp. date: XX/XX/XXXX

Attachment 5: Zika Virus Disease Enhanced Surveillance – Hospitalization associated with Zika virus disease

Demographic Information
Case ID (ArboNET):_____________________ Control for Case ID:____________________ State of residence:_____________________ County of residence:___________________ Age: ______  Years  Months  Days Sex:  Male  Female Pregnant:  Yes  No  Unknown Est Date Delivery: ____/____/____ OR Last Menstrual Period: ____/____/____ Race (Select all appropriate):  American Indian or Alaska Native  Asian  Black or African American  Native Hawaiian or Other Pacific Islander  White  Other  Unknown Ethnicity:  Hispanic or Latino  Not Hispanic or Latino  Unknown Imported From:  Not Imported  Acquired Out of State  Acquired Out of Country  Unknown Country of Origin:________________________________ Travel dates:____________________________ State of Origin:__________________________________ Travel dates: ____________________________ Other possible exposures:  Sexual  Breastfeeding  Blood products  Organs
Past Medical History
Hypertension		 Yes  No  Unk
Heart disease		 Yes  No  Unk
Diabetes mellitus		 Yes  No  Unk
Asthma/respiratory disease		 Yes  No  Unk Specify:_________________________________________
COPD		 Yes  No  Unk
Autoimmune disorder		 Yes  No  Unk
Cancer		 Yes  No  Unk
Other immune deficiency		 Yes  No  Unk
Liver/hepatic disease		 Yes  No  Unk
Kidney/renal disease		 Yes  No  Unk
Thyroid disease		 Yes  No  Unk
Seizure disorder		 Yes  No  Unk
Other neurologic disease		 Yes  No  Unk Specify:_________________________________________
Tobacco use		 Yes  No  Unk If yes:  Current  Past
Alcoholism		 Yes  No  Unk
Intravenous drug use		 Yes  No  Unk If yes:  Current  Past
Other medically important condition		 Yes  No  Unk Specify:_________________________________________
Pre-existing Medications and Treatments
Medications to treat hypertension				 Yes  No  Unk
Medications to treat coronary heart disease				 Yes  No  Unk
Medications to treat congestive heart failure				 Yes  No  Unk
Chemotherapy				 Yes  No  Unk
Other treatments for cancer				 Yes  No  Unk
Medications that suppress the immune system				 Yes  No  Unk
Insulin or other meds to treat diabetes				 Yes  No  Unk
Hemodialysis				 Yes  No  Unk
Other treatments for kidney disease				 Yes  No  Unk
Oral or injected steroids				 Yes  No  Unk
Clinical Information
Illness onset date: _____/_____/_____
Clinical syndrome:  Febrile illness  Encephalitis/meningoencephalitis  Meningitis  Acute flaccid paralysis  Guillain-Barré syndrome  Other neuroinvasive presentation  Other clinical
Case Status (ArboNET):  Confirmed  Probable
Fever	 Yes  No  Unk  Subjective  Measured (Max temperature: __________)
Chills/Rigors	 Yes  No  Unk
Rash	 Yes  No  Unk Type:  Maculopapular  Petechial  Purpuric  Other:____________________________________________ Pruritic:  Yes  No  Unk Distribution:­­­­­­­_______________________________________________
Headache	 Yes  No  Unk
Retro-orbital pain	 Yes  No  Unk
Conjunctivitis	 Yes  No  Unk
Oral ulcers	 Yes  No  Unk
Nausea/Vomiting	 Yes  No  Unk
Diarrhea	 Yes  No  Unk
Arthralgia	 Yes  No  Unk
Arthritis	 Yes  No  Unk
Myalgia	 Yes  No  Unk
Paresis/Paralysis	 Yes  No  Unk
Stiff Neck	 Yes  No  Unk
Ataxia	 Yes  No  Unk
Altered mental status	 Yes  No  Unk
Seizures	 Yes  No  Unk
Sore throat	 Yes  No  Unk
Cough	 Yes  No  Unk
Lymphadenopathy	 Yes  No  Unk
Paresthesia	 Yes  No  Unk
Abdominal pain	 Yes  No  Unk
Edema	 Yes  No  Unk Specify:__________________________________________________
Other	 Yes  No  Unk Specify:__________________________________________________
Outcomes
Emergency department	 Yes  No  Unk
Hospitalized	 Yes  No  Unk					Admission: ____/____/____ Discharge:____/____/____ Days hospitalized:______________ Multiple admissions:  Yes  No  Unk Number:__________
ICU	 Yes  No  Unk					Admission: ____/____/____ Discharge:____/____/____ Days in intensive care:____________ Intubation:  Yes  No  Unk
Admission diagnoses	Primary diagnosis or ICD 10:________________________________________________________ Additional diagnoses:_____________________________________________________________
Outcomes (continued)
Discharge diagnoses	Primary diagnosis or ICD 10:________________________________________________________ Additional diagnoses:_____________________________________________________________
Died	 Yes  No  Unk					Date of Death:_____/_____/_____ Causes of death: 1.________________________________________ 2.________________________________________ 3.________________________________________
Discharged to rehab	 Yes  No  Unk
Treatments Administered During Hospitalization
Antimicrobials			 Yes  No  Unk Specify:________________________________________
Steroids/other immune modulating			 Yes  No  Unk Specify:________________________________________
Blood products			 Yes  No  Unk Specify:________________________________________
Zika Virus Test Results							Dengue Virus Test Results
Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial							Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial
Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial							Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial
Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial							Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial
Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial							Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial
Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial							Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial
Laboratory Tests
CBC performed  Yes  No  Unk
	Leukopenia (<4,500) Thrombocytopenia (<150,000) Leukocytosis (>11,000)						 Yes  No  Unk  Yes  No  Unk  Yes  No  Unk		Nadir:_____ ; Date:__­­­­__/___/____ Nadir:_____ ; Date:__­­­­__/___/____ Max:______ ; Date:__­­­­__/___/____
Abnormal liver enzymes	AST:  Yes  No  Unk Max:_______; Date:__­­­­__/____/____ ALT:  Yes  No  Unk Max:_______; Date:__­­­­__/____/____
LP performed	 Yes  No  Unk				Date:___/____/____ WBC:_____________ RBC:______________ Protein:___________ Glucose:___________			Date:___/____/____ WBC:_____________ RBC:_____________ Protein:___________ Glucose:__________		Date:___/____/____ WBC:_____________ RBC:_____________ Protein:___________ Glucose:__________
MRI	 Yes  No  Unk				Date:___/____/____			Abnormal results:  Yes  No  Unk If yes, describe:________________________ _____________________________________
CT	 Yes  No  Unk				Date:___/____/____			Abnormal results:  Yes  No  Unk If yes, describe:________________________ _____________________________________
EMG/NCS	 Yes  No  Unk				Date:___/____/____			Abnormal results:  Yes  No  Unk If yes, describe:________________________ _____________________________________
Other test	 Yes  No  Unk				Date:___/____/____			Abnormal results:  Yes  No  Unk If yes, describe:________________________ _____________________________________

Public reporting burden of this collection of information is estimated to average 120 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-XXXX