OMB number here
Case ID: ___________________________ OMB expiration date here
Case Report Form for Histoplasmosis Enhanced Surveillance
CASE AND INTERVIEW INFORMATION (This section is for interviewer use only – do not read)
Date case was reported to the state health department (MM/DD/YY): _____________________
Interview date (MM/DD/YY): _____________________ Or □ Case-patient not interviewed (reason):_________________________________________________
Interviewer initials:________
Interview conducted with:
□ Case-patient
□ Other, specify relationship: _________________________
If interview was conducted with a proxy for the case-patient, indicate reason(s)
□ Case-patient unavailable
□ Case-patient is <18 years old
□ Case-patient deceased
How did histoplasmosis contribute to the death?
□ Histoplasmosis was the primary cause of death
□ Histoplasmosis was a related cause of death
□ Death was unrelated to histoplasmosis
□ Unknown
□ Other reason interview conducted with someone other than case, specify: ______________________
DEMOGRAPHICS
First, I’m going to ask some questions about yourself (Or case name, if interview conducted with someone else).
What is your (or name of case, if not interviewing case) date of birth? (MM/DD/YYYY): __________________
What sex were you assigned at birth, on your original birth certificate: □ Male □ Female □ Refused □ Don’t know
DIAGNOSIS, CLINICAL PRESENTATION, AND HEALTHCARE USE
Before this phone call, did you know about your positive test result [or diagnosis, for probable cases without laboratory testing] for histoplasmosis?
□ Yes □ No □ Don’t know
I’m going to be asking you some questions about dates. Do you have a calendar that you could look at?
Did you have symptoms of histoplasmosis? (if needed, prompt using the symptom list below)
□ Yes □ No (Skip to question 14) □ Don’t know
8a. (If yes) What date did your symptoms start? MM/DD/YY:_______________ □ Don’t know
Which of the following symptoms did you have? I’m going to read a list. (Check all that apply)
□ Fever □ Cough
□ Sore throat □ Coughing up blood
□ Chills □ Shortness of breath
□ Night sweats □ Wheezing
□ Chest pain □ Rash or other skin problem
□ Extreme tiredness □ Stiff neck
□ Headache □ Joint pain
□ Weight loss without trying □ Muscle pain
□ Other, specify: _________________________
What date did you first seek medical care for your symptoms? MM/DD/YY:_______________ □ Don’t know
Where did you first get medical care for your symptoms?
□ Primary care office
□ Urgent care clinic
□ Emergency room
□ Other, specify: _________________________
Did you ever go to the emergency room for your symptoms? □ Yes □ No □ Don’t know
How many times did you see a doctor or other healthcare provider for your symptoms before you were tested for histoplasmosis? _______ times □ Don’t know
Did you ask a doctor or other healthcare provider to test you for histoplasmosis? □Yes □No □Don’t know
Which type of healthcare provider first tested you for histoplasmosis? I’m going to read a list.
□ Primary care doctor, nurse practitioner, or physician assistant
□ Urgent care doctor
□ Emergency room doctor
□ Infectious disease doctor
□ Pulmonologist (lung specialist)
□ Other, specify: _________________________
□ Unknown
What date did your healthcare provider tell you that you had histoplasmosis?
MM/DD/YY:_____________________ □ Don’t know □ Didn’t tell me I had histoplasmosis
In what city and state was the healthcare provider who told you that you had histoplasmosis? ______________________
Did your healthcare provider diagnose you with another illness before he/she diagnosed you with histoplasmosis?
□ Yes, specify: ________________________________________ □ No □ Don’t know
Did your doctor prescribe you antibiotics before he/she diagnosed you with histoplasmosis? By “antibiotics,” I mean medicine to treat bacterial infections, which doesn’t work for histoplasmosis.
□ Yes □ No □ Don’t know
Were you ever hospitalized overnight for histoplasmosis? □ Yes □ No □ Don’t know
20a. (If yes) How long were you hospitalized? (#)_______days
Did your doctor do a chest x-ray or CT scan when diagnosing your illness? □ Yes □ No □ Don’t know
When your doctor told you that you had histoplasmosis, which parts of the body did he or she say were involved? I’m going to read a list. (Check all that apply)
□ Lungs
□ Brain or spinal cord
□ Bones or joints
□ Whole body
□ Other (Specify):____________________________________
□ The test was positive, but no specific body part was involved
□ The doctor didn’t tell me / I don’t know
TREATMENT AND OUTCOMES
Did your doctor prescribe you antifungal medicine(s) to treat histoplasmosis? □ Yes □ No □ Don’t know
23a. (If yes) What was the name of the medicine(s)? I’m going to read a list. (Check all that apply)
□ Amphotericin B, given IV in hospital □ Voriconazole (VFEND)
□ Fluconazole (Diflucan) □ Other, specify______________________________
□ Itraconazole (Sporanox) □ Don’t know
□ Posaconazole
23b. How long did you take antifungal medicine(s) to treat histoplasmosis?
(#)_______days (#)_______weeks (#)_______months □ Still taking (see 23c)
23c. (If still taking antifungals) How long did your doctor say you need to take antifungal medicine, in total?
(#)_______days (#)_______weeks (#)_______months □ Don’t know
Total, how long did your histoplasmosis symptoms last?
(#)_______days (#)_______weeks (#)_______months
□ Not yet recovered □ Don’t know □ Not applicable; no symptoms
Did you have a job or were you in school when you got histoplasmosis?
□ Yes, a job , specify: _____________________________ □ Yes, in school □ No
25a. (If yes) Did you miss any time from your job or school due to histoplasmosis?
□ Yes, (#)_______days □ No □ Don’t know
Did histoplasmosis interfere with your ability to do your usual daily activities?
□ Yes □ No □ Don’t know
26a. (If yes) For how long? (#)_______days (#)_______weeks (#)_______months □ Don’t know
MEDICAL HISTORY
Now I’m going to ask some questions about your overall health and any past medical problems.
Have you ever smoked tobacco, such as cigarettes, cigars, or pipes?
□ Yes, currently □ Yes, in the past □ No □ Unknown
Did you have any of the following medical conditions when you were diagnosed with histoplasmosis? I’m going to read a list.
□ Asthma requiring an inhaler
□ Autoimmune disease, specify: _________________________
□ COPD or emphysema
□ Other lung disease, specify: _________________________
□ Diabetes
□ HIV/AIDS. If yes: were you taking HIV medicine (antiretroviral therapy) when you got histoplasmosis?____
□ Heart disease, specify: _________________________
□ Cancer, specify: _________________________
□ Organ transplant or bone marrow transplant, specify: _________________________
□ Liver disease
□ Kidney disease
□ Pregnancy
□ Other major illnesses, specify: _________________________
□ Unknown
Before you were diagnosed with (or had a positive test for) histoplasmosis, were you taking any medications that affect your immune system? Examples are steroids such as prednisone or dexamethasone, interferon, chemotherapy medications, methotrexate, medications to prevent organ transplant rejection, or any TNF inhibitor such as Remicade, Enbrel, or Humira.
□ Yes □ No □ Don’t know
29a. (If yes) What medication(s): ___________________________________________________________
From _____________________(MM/YY) to _____________________(MM/YY) or □ still taking
Before this diagnosis of histoplasmosis, had a doctor ever told you that you had histoplasmosis in the past?
□ Yes □ No □ Don’t know
30a. (If yes) When? _________________________(approximate date)
RESIDENCE AND EXPOSURES
My next set of questions is about where you live and your activities.
What city and state did you live in when you were diagnosed with histoplasmosis? _____________________
31a. How long had you lived in (state named above) before you were diagnosed with histoplasmosis?
(#)_______months (#)_______years
Is your home located in an urban, suburban, or rural area? □ Urban □ Suburban □ Rural □ Don’t know
In the one month before your first symptoms of histoplasmosis, did you travel out of your home state? (If no symptoms, please ask about month before diagnosis by laboratory test.)
□ Yes, specify:_________________________________________ □ No □ Don’t know
In the one month before your first symptoms of histoplasmosis, did you do any of the following activities, or were you near any of the following activities? (If no symptoms, ask about month before diagnosis by laboratory test. Check all that apply. If yes to any, ask in what city/state or city/country if outside the U.S., and ask specifically where, e.g., home/work, another building, name of cave, etc.)
□ Dig in soil City/state:_______________ Specific location:___________________
□ Go in a barn City/state:_______________ Specific location:___________________
□ Go in a cave City/state:_______________ Specific location:___________________
□ Handle bird poop City/state:_______________ Specific location:___________________
□ Handle bat poop City/state:_______________ Specific location:___________________
□ Clean a chicken coop City/state:_______________ Specific location:___________________
□ Construction City/state:_______________ Specific location:___________________
□ Demolition or renovation City/state:_______________ Specific location:___________________
□ Excavation City/state:_______________ Specific location:___________________
□ Clean attic or chimney City/state:_______________ Specific location:___________________
□ Hiking City/state:_______________ Specific location:___________________
□ Hunting City/state:_______________ Specific location:___________________
□ Camping City/state:_______________ Specific location:___________________
□ Heating or air conditioning work City/state:_______________ Specific location:___________________
□ Gardening or landscaping City/state:_______________ Specific location:___________________
□ Other handling of plants or trees City/state:_______________ Specific location:___________________
Describe:__________________________________________________________
□ Other exposures to birds, bats, or soil disruption? City/state:___________ Specific location:___________
Describe:__________________________________________________________
Has anyone else you know also recently been diagnosed with histoplasmosis?
□ Yes, specify who/when:_________________________________________ □ No □ Don’t know
Did you know about histoplasmosis before you were diagnosed with it (or tested positive for it)?
□ Yes □ No □ Don’t know
36a. (If yes) How did you first hear about it? (e.g., the Internet, a family member, TV, etc.)_______________
How and where do you think that you got histoplasmosis? ________________________________________
________________________________________________________________________________________
I have a few more questions about yourself (or name of case, if not interviewing case).
Are you Hispanic or Latino? □ Yes □ No □ Refused
Which of the following best describes your race? I’m going to read a list, and you can pick more than one.
□ White
□ Black or African American
□ Asian
□ American Indian or Alaska Native
□ Native Hawaiian or Other Pacific Islander
□ Other, specify: _________________________
□ Refused
INSURANCE, EDUCATION, AND INCOME
We’re almost done. Thanks for your patience. I just have a few more questions for you, which are about your health insurance and education.
When you got histoplasmosis, did you have health insurance? □ Yes □ No □ Don’t know
How far did you go in school? I’m going to read a list of choices.
□ No high school
□ Some high school
□ High school graduate / GED
□ Technical school / certificate / apprenticeship
□ Some college / associate degree
□ College graduate / bachelor’s degree
□ Post-graduate / professional degree
□ Don’t know
□ Refused
Because income can affect a person’s ability to receive healthcare, I’d like to ask you about your total yearly household income from all sources. Which income group best represents the total yearly income for your household when you had histoplasmosis? I’m going to read a list, and you can stop me when I get to the right category.
□ Less than $15,000
□ Between $15,001 and $25,000
□ Between $25,001 and $35,000
□ Between $35,001 and $50,000
□ Over $50,000
□ Refused
That’s all the questions I have for you. Thank you very much for your time. Do you have any questions for me?
(Record any questions here):___________________________________________________________________
___________________________________________________________________________________________
Interviewer notes; attach additional notes pages as needed:__________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
DIAGNOSIS OF HISTOPLASMOSIS Please record all histoplasmosis laboratory test results below.
Test type |
Specimen type |
Collection date |
Result |
Value, if applicable |
Laboratory that performed the test |
Complement fixation |
|
|
□pos □neg □unk |
Titer:_______ |
|
|
|
□pos □neg □unk |
Titer:_______ |
|
|
|
|
□pos □neg □unk |
Titer:_______ |
|
|
Immunodiffusion, H band |
|
|
□pos □neg □unk |
|
|
|
|
□pos □neg □unk |
|
|
|
|
|
□pos □neg □unk |
|
|
|
Immunodiffusion, M band |
|
|
□pos □neg □unk |
|
|
|
|
□pos □neg □unk |
|
|
|
|
|
□pos □neg □unk |
|
|
|
Antigen, EIA |
|
|
□pos □neg □unk |
____ng/ml or index:____ |
|
|
|
□pos □neg □unk |
____ng/ml or index:____ |
|
|
Antigen, LFA |
|
|
□pos □neg □unk |
Concentration:_________ |
|
Culture |
|
|
□pos □neg □unk |
|
|
DNA probe for culture confirmation |
|
|
□pos □neg □unk |
|
|
Histopathology |
|
|
□pos □neg □unk |
|
|
PCR |
|
|
□pos □neg □unk |
|
|
Cytopathology/smear |
|
|
□pos □neg □unk |
|
|
Record any additional lab test results here: _______________________________________________________________________________________________
Additional questions related to diagnosis
Case status: □ Confirmed □ Probable (indicate category below)
□ Clinically-compatible case that meets non-confirmatory lab criteria
□ Case meets confirmed lab criteria, but no clinical information is available
□ Clinically-compatible case that does not meet lab criteria, but is epi-linked to a confirmed case
Did the provider diagnose this illness as histoplasmosis?
□ Yes (indicate type below, if known)
□ Acute pulmonary histoplasmosis
□ Chronic pulmonary histoplasmosis
□ Disseminated histoplasmosis
□ Other, specify:__________________________________
□ Unknown
□ No, not histoplasmosis. Other diagnosis:_____________________________________________________
□ Unknown, etiology unclear, or diagnosis not recorded
What was the reason for histoplasmosis testing?_________________________________________________
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-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Kaitlin Benedict |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |