National Adenovirus Type Reporting System (NATRS) Report Form | Form Approved | |||||||||||||||||||||||||
OMB No. 0920-0004 | ||||||||||||||||||||||||||
Positive Test Results | Adenovirus 1 | Adenovirus 2 | optional information | |||||||||||||||||||||||
Reporting Lab | Report Date | Age (# Only) | Age Type (Months or Years) | Sex (M/F/U) | State of Residence (see codes--2rd sheet) | Specimen Type (see legend--far right) | Specimen Collection Date (mm/dd/yyyy) | AdV Species (A-F) | AdV Type | AdV Species (A-F) | AdV Type | Hospitalized (Y/N/U) | Outbreak(Y/N/U) | Specimen Legend | ||||||||||||
Primary Specimen or culture Isolate | 1 | NP/OP swab | ||||||||||||||||||||||||
Specimen Type-Specified | or Culture Isolate | Number of AdV | HAdV Species/Type | Coinfection detected | Outbreak Type | Comments/Other | 2 | NP/OP wash | ||||||||||||||||||
detected | determined by | Type Determined by | Coinfection detected | Specify | Fatal (Y/N/U) | (see legend--far right) | 3 | Sputum | ||||||||||||||||||
(see legend-far right) | Other (please specify) | (Y/N/U) | (please indicate pathogen(s) detected | 4 | Tracheal Aspirate | |||||||||||||||||||||
5 | Bronchoalveolar Lavage | |||||||||||||||||||||||||
6 | Pleural Fluid | |||||||||||||||||||||||||
7 | Ocular Swab | |||||||||||||||||||||||||
10 | Stool | |||||||||||||||||||||||||
11 | Tissue(Specify)__________ | |||||||||||||||||||||||||
8 | Other(Specify)_________________ | |||||||||||||||||||||||||
9 | Unknown | |||||||||||||||||||||||||
Human Adenovirus species/Type determined by | ||||||||||||||||||||||||||
1 | Sequencing Hexon Gene | |||||||||||||||||||||||||
2 | Sequencing Fiber Gene | |||||||||||||||||||||||||
3 | Next Gen Sequencing | |||||||||||||||||||||||||
4 | Sequencing Other | |||||||||||||||||||||||||
5 | Real time PCR | |||||||||||||||||||||||||
6 | Commercial Molecular Assay (ie. GenMark) | |||||||||||||||||||||||||
7 | Serum Neutralization | |||||||||||||||||||||||||
8 | Other(Specify)_________________ | |||||||||||||||||||||||||
9 | Unknown | |||||||||||||||||||||||||
10 | Sequencing Hexon and Fiber Gene | |||||||||||||||||||||||||
Outbreak Type | ||||||||||||||||||||||||||
1 | Hospital | |||||||||||||||||||||||||
2 | School | |||||||||||||||||||||||||
3 | Daycare | |||||||||||||||||||||||||
4 | Long Term Care Facility | |||||||||||||||||||||||||
5 | Military | |||||||||||||||||||||||||
8 | Other (specify) _______ | |||||||||||||||||||||||||
9 | Unknown | |||||||||||||||||||||||||
Adenovirus Source | ||||||||||||||||||||||||||
1 | Primary Specimen | |||||||||||||||||||||||||
2 | Culture Isolate | |||||||||||||||||||||||||
3 | Nucleic Acid | |||||||||||||||||||||||||
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). |
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 |
Species | |
1 | A |
2 | B |
3 | C |
4 | D |
5 | E |
6 | F |
7 | B/E |
Type | |
1 | |
2 | |
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35 | |
36 | |
37 | |
38 | |
39 | |
40 | |
41 |
1 | Yes | |
2 | No | |
3 | Unknown | |
Age | ||
1 | Months | |
2 | Years | |
Specimen | ||
1 | Primary | |
2 | Culture Isolate | |
Gender | ||
1 | Male | |
2 | Female | |
9 | Unknown | |
adenovirus source | ||
Primary Specimen | ||
Culture Isolate | ||
Other (specify) _______ | ||
Nucleic Acid | ||
Unknown | ||
Outbreak Type | ||
1 | Hospital | |
2 | School | |
3 | Daycare | |
4 | Long Term Care Facility | |
5 | Military | |
8 | Other (specify) _______ | |
9 | Unknown | |
Specimen Legend | ||
1 | NP/OP swab | |
2 | NP/OP wash | |
3 | Sputum | |
4 | Tracheal Aspirate | |
5 | Bronchoalveolar Lavage | |
6 | Pleural Fluid | |
7 | Ocular Swab | |
10 | Stool | |
11 | Tissue(Specify)__________ | |
8 | Other(Specify)_________________ | |
9 | Unknown | |
Human Adenovirus species/Type determined by | ||
Sequencing Hexon Gene | ||
Sequencing Fiber Gene | ||
Next Gen Sequencing | ||
Sequencing Other | ||
Real time PCR | ||
Commercial Molecular Assay (ie. GenMark) | ||
Serum Neutralization | ||
Other(Specify)_________________ | ||
Unknown | ||
10 | Sequencing Hexon and Fiber Gene |
File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |