Suspect Respiratory Virus Patient Form

Suspect Respiratory Virus Patient Form Form Approved

OMB No. 0920-0004

Complete for all patients for whom specimens are submitted to CDC for virus testing. As soon as possible, please 1) notify and send the completed form to your local/state health department, and 2) include a hard copy of the form along with the 50.34 form for specimen shipment.

Today’s Date:       Name of person filling in form:       Phone:       Email:      

Hospital / Health Care Facility Name:       STATE:       COUNTY:      

<MANDATORY> Local Specimen ID (as submitted on 50.34 form for specimen shipment):      

If multiple specimens are submitted per patient, please include additional specimen IDs in table below

Patient Sex: M F Age:       Days Months Years Patient’s State of Residence      

Race: (More than one box can be checked) Asian Black or African American Native Hawaiian or Other Pacific Islander

American Indian or Alaska Native White Ethnicity: Hispanic Non-Hispanic

Was patient part of an outbreak? Y N If yes, indicate setting: Hospital School Daycare LTCF Unknown Other      

Date of symptom onset:       Medical diagnosis (if any, e.g., pneumonia, asthma exacerbation):      

Symptoms (mark all that apply): Fever reported (≥100.4° F / 38° C (If yes, highest recorded temperature       °F / °C))

Chills Cough Wheezing Sore throat Runny nose Stuffy nose/congestion

Shortness of breath / difficulty breathing Tachypnea Retractions Cyanosis Vomiting

Diarrhea Rash Lethargy Seizure Conjunctivitis Other (describe):      

Does the patient have any comorbid conditions or concurrent risk factors? (mark all that apply): None Unknown

Asthma Reactive airway disease / COPD Bronchopulmonary dysplasia Cardiac disease Immunocompromised

Prematurity, if yes gestational age       Wheezing Pregnancy Smoking Other (describe):      

Diagnostic Imaging (Chest radiograph / CT / Other) Yes No Not Done Unknown

If yes, please describe any abnormal findings:      

	Yes	No	Unknown
Is/Was the patient: Hypoxic (sat <93%) on room air?
Treated with supplemental oxygen?
Treated with bronchodilators? (if yes, name: ____________________________________)
Treated with steroids? (if yes, name: ___________________________________________)
Treated with antibiotics? (if yes, name: _________________________________________)
Hospitalized? If Yes, admission date:      ; discharge date, if applicable:      
If Yes, was the patient admitted to the Intensive Care Unit (ICU)?
If Yes was the patient placed on non-invasive ventilation (BiPAP/CPAP)
If Yes, was the patient intubated?
If Yes, was the patient placed on ECMO?
Did the patient die? If Yes, date of death:      

General Pathogen Laboratory Testing (mark all that apply)
Pathogen	Pos	Neg	Pending	Not Done	Pathogen	Pos	Neg	Pending	Not Done
Influenza A PCR					Chlamydophila pneumoniae
Influenza B PCR					Mycoplasma pneumoniae
Influenza Rapid Test					Legionella pneumophila
RSV					Streptococcus pneumoniae
Human metapneumovirus					Blood culture
Parainfluenzavirus					If positive,specify pathogen:      
Adenovirus					CSF culture
Rhinovirus and/or Enterovirus					If positive, specify pathogen:      
Coronavirus (not MERS-CoV)					Sputum culture
Other:      					If positive, specify pathogen:      
Other:      

Submitted Specimen Type(s)	Date Collected	Specimen ID	Submitted Specimen Type(s)	Date Collected	Specimen ID
NP OP NP/OP (check one)	     	     	Bronchoalvelolar lavage (BAL)	     	     
Nasal wash / aspirate	     	     	Tracheal Aspirate	     	     
Sputum	     	     	Stool/Rectal swab	     	     
Other:      	     	     	Other:      	     	     

To be completed by CDC: Patient ID:       CSID:       CSID:       CSID:       CSID:       CSID:      

Public reporting burden of this collection of information is estimated to average 30 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). Version 1.0 (fillable), March 24, 2017