Acute Respiratory Infection and Influenza Surveillance F

U.S. Department of Health and Human Services (HHS) OMB Control # 0920-XXXX

Centers for Disease Control and Prevention (CDC) Expiration Date XX/XX/XXXX

Wisconsin Influenza and Acute respiratory Infection Surveillance

Acute Respiratory Infection and Influenza Surveillance Form

School ID: _______________

Participant ID: ____________

Name: ___________________

DOB: ___ / ___ / ___

Criteria for patient selection and testing

• symptom onset within 4 days

• any two of the following

  

  ORegon CHild Absenteeism due to Respiratory Disease Study

  
  

  • rhinorrhea

  • nasal congestion

  • sneezing

  • sore throat

  • cough

  • fever

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Days between illness onset and today’s visit: ____ days

Exposure to a similar illness 1-3 days prior to ARI onset? Yes No

Recent Travel? Yes No Recent Exposuree to Farm Animals? Yes No

Severity of Illness (circle): Mild Moderate Severe

Ethnicity:

-- Hispanic or Latino

-- Not Hispanic or Latino

Race: White American Indian or Alaska Native Asian Black or African American

Native Hawaiian or Other Pacific Islander

Measured Temperature ___ ^oF Antipyretic use within the last 6 hours? Yes No

Symptoms (circle all that are present):

Fever Chills Cough Wheezing Runny Nose

Sore Throat Malaise Myalgia Arthralgia Nasal Congestion

Headache Ear Pain Anorexia Vomiting Abdominal Pain

Diarrhea Conjunctivitis Other: ___________________________________

Influenza antiviral treatment for this illness prior to this visit? Yes No

Seasonal influenza vaccine prior to this illness? Yes No

Indicate Specimen Type(s) for PCR testing: nasopharynx posterior pharynx

- - - - - - - - - - ITEMS BELOW THIS LINE FOR LABORATORY ONLY - - - - - - - -

Sofia Result:  flu A  flu B  both  negative  invalid

Sample Code: _ORCHARDS_ - _____ - ____ - ______

site week staff sample ___________________________________________________________________________

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