CDC 2016 Surveillance for Non-Invasive Penumococcal Pneumoni

– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

Patient’s Name:

Phone No.: (
Patient
Chart No.:

(Last, First, MI.)

Address:

(Number, Street, Apt. No.)
(City, State)

2016 SURVEILLANCE FOR NON-INVASIVE
PNEUMOCOCCAL PNEUMONIA (SNiPP)

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
ATLANTA, GA 30333

CASE REPORT FORM

Expiration Date: 02/28/2019
1. STATE:

OMB No. 0920-0978

– SHADED AREAS FOR OFFICE USE ONLY –

2. STATE I.D.:

3a. DATE FIRST POSITIVE URINE
ANTIGEN TEST COLLECTED
(Date Specimen Collected)

(Residence of Patient)

Mo.

Day

4. CRF Status:

3b. TYPE OF TEST

Year

1

Binax Now

2

BD Directigen

3

Other (specify) ____________

9

Unknown

7. DATE OF BIRTH:

9. SEX:

8a. AGE:

Day

Year

1

Complete

3

Edited & Correct

2

Incomplete

4

Chart unavailable
after 3 requests

6b. HOSPITAL I.D. WHERE
PATIENT TREATED:

6a. HOSPITAL/LAB I.D. WHERE
UAT IDENTIFIED:

5. COUNTY:
(Residence of Patient)

Mo.

Hospital:

(Zip Code)

er information is not transmitted to CDC –

10b. RACE: (Check all that apply)

10a. ETHNIC ORIGIN:

1

Male

1

Hispanic or Latino

2

Female

2

Not Hispanic or Latino

9

Unknown

1

White

1

Asian

1

Black

1

1

American Indian
or Alaska Native 1

Native Hawaiian
or Other Pacific Islander

7

1

Private residence

3

Long term acute care facility

5

Incarcerated

2

Long term care facility

4

Homeless

6

College dormitory 8

12b. HOSPITAL DISCHARGE DATE
(From second hospital, if transferred)

12a. HOSPITAL ADMISSION DATE
Day

Year

14. OUTCOME: 1

Mo.

Survived 2

Died 9

Day

Year

Non-medical ward

9

Yes

2

Unknown

Other (specify) ____________

12c. Was this patient admitted to
the ICU during hospitalization?
1

No

9

13a. WEIGHT: ______lbs______ oz OR ______ kg

Unknown

OR

Unknown

13b. HEIGHT: ______ft ______ in OR ______ cm OR

Unknown

13c. BMI: ___ ___ . ___

1
1

AIDS or CD4 count <200
Alcohol Abuse, Current

1

Cochlear Implant

1

Complement Deficiency

1
1
1

Alcohol Abuse, Past
Asthma
Atherosclerotic Cardiovascular Disease
(ASCVD)/CAD

1

CSF Leak

1

Current Smoker

1

Deaf/Profound Hearing Loss

1
1
1
1
1
1

Bone Marrow Transplant (BMT)
Cerebral Vascular Accident (CVA)/Stroke
Chronic Kidney Disease
Current Chronic Dialysis
Chronic Skin Breakdown
Cirrhosis/Liver Failure

1

Dementia

1

Diabetes Mellitus

1
1
1
1
1

Emphysema/COPD
Heart Failure/CHF
HIV Infection
Hodgkin’s Disease/Lymphoma
Immunoglobulin Deficiency

X-ray 3

Both 4

Neither 9

1
1

IVDU, Past

1
1
1
1
1
1

Leukemia
Multiple Myeloma
Multiple Sclerosis
Nephrotic Syndrome
Neuromuscular Disorder
Obesity

1
1

Parkinson’s Disease
Other Drug Use, Current

Unknown

1

Air space/alveolar density/opacity/disease

1

Consolidation

1

Empyema

1

Lobar (NOT interstitial) infiltrate

1

None of the above diagnoses were listed

1

Report not available

18. WAS THE PATIENT DIAGNOSED WITH PNEUMONIA WITHIN 72 HOURS OF THE POSITIVE UAT?:

Other Drug Use, Past

1

Peripheral Neuropathy

1
1
1
1
1
1
1

Plegias/Paralysis
Seizure/Seizure Disorder
Sickle Cell Anemia
Solid Organ Malignancy
Solid Organ Transplant
Splenectomy/Asplenia
Systemic Lupus Erythematosus (SLE)

1

Other prior illness (specify)

1

Yes

2

No 9

Unknown

If YES, please note which pneumococcal vaccine was received:

If yes, check all that apply from the radiology report:
Pneumonia/bronchopneumonia

Unknown

1

17a. Did patient receive pneumococcal vaccine during this hospitalization?

Unknown

1

19. COMMENTS

None 1

Immunosuppressive Therapy (Steroids,
Chemotherapy, Radiation)
IVDU, Current

1

16. DID THE PATIENT HAVE A CHEST CT OR CHEST X-RAY WITHIN 72 HOURS OF THEIR POSITIVE UAT?:
CT 2

OR

Unknown

15. UNDERLYING CAUSES OR PRIOR ILLNESSES: (Check all that apply OR if NONE or CHART UNAVAILABLE,check appropriate box) 1

1

Unknown

11b. If resident of a facility, what
was the name of the facility?

11a. WHERE WAS THEPATIENT A RESIDENT AT THE TIME OF POSITIVE UAT?:

Mo.

)

®
®

1

Prevnar-13 , 13-valent Pneumococcal Conjugate Vaccine (PCV13)

1

Pneumovax , 23-valent Pneumococcal Polysaccharide Vaccine (PPV23)

1

Vaccine type not specified

17b. If YES, please add date of vaccination:

Mo.

Day

Year

Unknown
1

Yes

2

No

9

Unknown
20. INITIALS OF S.O.

Public reporting burden of this collection of information is estimated to average 10 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
Page 1 of 1
CDC 52.15A REV. 10-2015
– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –
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
information, including suggestions for reducing this burden to CDC, CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30329, ATTN: PRA(0920-0978)