National Adenovirus Type Reporting System (NATRS) Form

National Disease Surveillance Program - II. Disease Summaries

Attachment W_National Adenovirus Type Reporting System (NATRS) Report Form.xlsx

Att W Adenovirus Typing Report Form

OMB: 0920-0004

Document [xlsx]
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Overview

REPORT FORM
STATE FIPS CODE LIST
AdeSpecies
Other


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).







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

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

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
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