National Adenovirus Type Reporting System (NATRS) Form

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Overview

REPORT FORM
STATE FIPS CODE LIST
AdeSpecies
Other

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Sheet 1: REPORT FORM

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).

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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

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Sheet 3: AdeSpecies

	Species
1	A
2	B
3	C
4	D
5	E
6	F
7	B/E
	Type
	1
	2
	3
	4
	5
	6
	7
	8
	9
	10
	11
	12
	13
	14
	15
	16
	17
	18
	19
	20
	21
	22
	23
	24
	25
	26
	27
	28
	29
	30
	31
	32
	33
	34
	35
	36
	37
	38
	39
	40
	41

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Sheet 4: Other

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