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pdf2017-18 FluSurv-NET Influenza Hospitalization
Surveillance Project Case Report Form
U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
ATLANTA, GA 30333
1
Case ID:
7
1
Form Approved
OMB No. 0920-0978
8
A. Patient Data – THIS INFORMATION IS NOT SENT TO CDC
First Name:
Last Name:
Address:
Middle Name:
Address Type:
(Number, Street, Apt. No.)
(City)
(State)
Phone No.2:
Chart No. :
Phone No. 1:
(Zip Code)
Emergency Contact:
Emergency Contact Phone:
No PCP
PCP Clinic Name 1:
PCP Phone 1:
PCP Fax 1:
PCP Clinic Name 2:
PCP Phone 2:
PCP Fax 2:
Site Use 2:
Site Use 1:
Site Use 3:
B. Abstractor Information – THIS INFORMATION IS NOT SENT TO CDC
1. Abstractor Name:
2. Date of Abstraction:
C. Enrollment Information
1. Case Classification:
Prospective Surveillance
6. Date of Birth:
/
Discharge Audit
7. Age:
Years
Hispanic or Latino
3. County:
(if < 1 month)
9. Race:
Male
Female
(if < 1 yr)
/
4. State:
5. Case Type:
Pediatric
Observation Only
8. Sex:
Days
Months
/
10. Ethnicity:
2. Admission Type:
Hospitalization
/
White
Black or African American
Asian/Pacific Islander
American Indian or Alaska Native
Multiracial
Not specified
12. Was patient discharged from any hospital within 1 week prior to the
current admission date?
Yes
No
Unknown
11. Hospital ID Where Patient Treated:
Non-Hispanic or Latino 11a. Admission Date:
/
/
13. Was patient transferred from another hospital?
Not Specified
/
/
13a. Transfer Hospital ID:
11b. Discharge Date:
Adult
14. Where did patient reside at the time of hospitalization? (Indicate TYPE of residence.)
Private residence
Hospice
Assisted living/Residential care
Homeless/Shelter
LTACH
Nursing home/Skilled Nursing Facility
Group home/Retirement
Alcohol/Drug Abuse Treatment
Mental Hospital
Hospitalized at birth
Unknown
Rehabilitation facility
Other long term care facility
Jail/Prison
/
15. Type of Insurance:
14a. If resident of a facility, indicate NAME of facility:
Unknown
/
/
(Check all that apply):
Private
Medicare
Medicaid/state assistance program
Military
Indian Health Service
Other, specify:
No
/
13b. Transfer Hospital Admission Date:
13c. Transfer Date:
Yes
Incarcerated
Uninsured
Unknown
Other, specify:
D. Influenza Testing Results (can add up to 4 test results in database)
1. Test 1:
1a. Result:
Rapid Antigen
Molecular Assay
/
1b. Specimen collection date:
2. Test 2:
2a. Result:
Rapid Antigen
3a. Result:
H1, Seasonal
H1
H3
Flu A (no subtype)
2009 H1N1
H1, Unspecified
Rapid Antigen
/
/
Molecular Assay
H1, Seasonal
H1
H3
Flu A (no subtype)
2009 H1N1
H1, Unspecified
3b. Specimen collection date:
/
Molecular Assay
2b. Specimen collection date:
3. Test 3:
H1, Seasonal
H1
H3
Flu A (no subtype)
2009 H1N1
H1, Unspecified
/
/
Rapid Molecular Assay
Flu A, Unsubtypable
Flu B (no lineage)
Flu B, Victoria
Viral Culture
Flu B, Yamagata
Flu A & B
Flu A/B (Not Distinguished)
1c. Testing facility ID:
Rapid Molecular Assay
Flu A, Unsubtypable
Flu B (no lineage)
Flu B, Victoria
Flu A, Unsubtypable
Flu B (no lineage)
Flu B, Victoria
Fluorescent Antibody
Unknown Type
Negative
H3N2v
Method Unknown
Other, specify:
1d. Specimen ID:
Viral Culture
Serology
Flu B, Yamagata
Flu A & B
Flu A/B (Not Distinguished)
2c. Testing facility ID:
Rapid Molecular Assay
Serology
Fluorescent Antibody
Unknown Type
Negative
H3N2v
Method Unknown
Other, specify:
2d. Specimen ID:
Viral Culture
Serology
Flu B, Yamagata
Flu A & B
Flu A/B (Not Distinguished)
3c. Testing facility ID:
Fluorescent Antibody
Unknown Type
Negative
H3N2v
Method Unknown
Other, specify:
3d. Specimen ID:
Public reporting burden of this collection of information is estimated to average 25 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 Information Collection Request Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0978).
Page 1 of 4
2017-18 FluSurv-NET Influenza Hospitalization
Surveillance Project Case Report Form
1
Case ID:
7
1
8
E. Admission and Patient History
/
1. Date of onset of acute condition resulting in current hospitalization:
/
2. Acute signs/symptoms present at admission (began or worsened within 2 weeks prior to admission):
Non-respiratory symptoms
Fatigue/weakness
Fever/chills
Headache
Myalgia/muscle aches
Nausea/vomiting
Rash
Seizures
Other, non-respiratory
/
3. Date of onset of acute respiratory symptoms (within 2 weeks before a positive flu test):
6. Weight:
5. Height:
Unk
In
Cm
Lbs
Unk
Kg
Unk
7. Smoker (tobacco):
Former
Current
Opioids
Other, specify:
No/Unknown
11b. Chronic Lung Disease
Yes
No/Unknown
Yes
No/Unknown
Yes
No/Unknown
Yes
No/Unknown
Active Tuberculosis/TB
Cystic fibrosis
Emphysema/COPD
Chronic bronchitis
Chronic respiratory failure
Other, specify:
11c. Chronic Metabolic Disease
Diabetes Mellitus
Thyroid dysfunction
Other, specify:
11d. Blood disorders/Hemoglobinopathy
Aplastic anemia
Sickle cell disease
Splenectomy/Asplenia
Other, specify:
11e. Cardiovascular Disease
Aortic aneurysm
Aortic stenosis
Atrial Fibrillation
Cardiomyopathy
Atherosclerotic cardiovascular disease (ASCVD)
Cerebral vascular incident/Stroke
Congenital heart disease
Coronary artery disease (CAD)
Ischemic cardiomyopathy
Non-ischemic cardiomyopathy
Heart failure/CHF
Other, specify:
11f. Neuromuscular disorder
Duchenne muscular dystrophy
Muscular dystrophy
Multiple sclerosis
Mitochondrial disorder
Myasthenia gravis
Parkinson’s disease
Other, specify:
11g. Neurologic disorder
Yes
Yes
Unknown
8. Alcohol abuse:
Current
(check all that apply):
11. Did patient have any of the following pre-existing medical conditions? Check all that apply.
Yes
/
Yes
No
Marijuana
Current
Former
No/Unk
Yes
No/Unknown
E-cigarettes
Other
Unknown
11h History of Guillain-Barré Syndrome
Yes
No/Unknown
11i. Immunocompromised Condition
Yes
No/Unknown
AIDS or CD4 count < 200
Cancer: current/in treatment or diagnosed in last 12 months
Complement deficiency
HIV Infection
Immunoglobulin deficiency
Immunosuppressive therapy
Organ transplant
Stem cell transplant (e.g., bone marrow transplant)
Steroid therapy (taken within 2 weeks of admission)
Other, specify:
11j. Renal Disease
Yes
No/Unknown
Chronic kidney disease/chronic renal insufficiency
End stage renal disease/Dialysis
Glomerulonephritis
Nephrotic syndrome
Other, specify:
11k. Liver disease
Yes
No/Unknown
Cirrhosis
Viral hepatitis (B or C)
Other, specify:
11l. Any obesity
Obese
Morbidly obese (ADULTS ONLY)
11m. Pregnant
No/Unknown
Not applicable
9. Substance abuse:
Former
(Optional) 10. Current Non-Tobacco Smoker:
Unknown
11a. Asthma/Reactive Airway Disease
Congested/runny nose
URI/ILI
Cough
Wheezing
Shortness of breath/respiratory distress
Sore throat
No/Unk
No/Unk
9a. Substance Abuse Type (current use only) (check all that apply):
IVDU
No Signs/Symptoms
Respiratory symptoms
Altered mental status/confusion
Chest pain
Conjunctivitis/pink eye
Diarrhea
4. BMI:
Unknown
Yes
No/Unknown
Yes
If pregnant, specify gestational age in weeks:
Unknown gestational age
11n. Post-partum (two weeks or less)
Yes
11o. Other
Yes
Systemic lupus erythematosus/SLE/Lupus
Other, specify:
No/Unknown
No/Unknown
No/Unknown
11p. PEDIATRIC CASES ONLY
Yes
No/Unknown
Abnormality of upper airway
Yes
No/Unknown
History of febrile seizures
Yes
No/Unknown
Long-term aspirin therapy
Yes
No/Unknown
Premature
(gestation age < 37 weeks at birth for patients < 2yrs)
If yes, specify gestational age at birth in weeks:
Unknown gestational age at birth
No/Unknown
Cerebral palsy
Cognitive dysfunction
Dementia/Alzheimer’s disease
Developmental delay
Down syndrome
Plegias/Paralysis
Seizure/Seizure disorder
Other, specify:
Page 2 of 4
2017-18 FluSurv-NET Influenza Hospitalization
Surveillance Project Case Report Form
1
Case ID:
7
1
8
F. Intensive Care Unit and Interventions (can record up to 3 ICU stays in database)
1. Was the patient admitted to an intensive care unit (ICU)?
1a. Number of ICU Admissions:
Yes
No
Unknown
2. Did patient receive invasive mechanical ventilation?
3. Did patient receive extracorporeal membrane oxygenation
(ECMO or ‘on bypass’)?
Yes
Unknown
1b. Date of first ICU Admission:
/
/
Unknown
1c. Date of first ICU Discharge:
/
/
Unknown
Yes
No
Unknown
No
Unknown
G. Bacterial Pathogens – Sterile or respiratory site only (can record up to 5 pathogens in database)
1. Were any bacterial culture tests performed with a collection date within three days of admission?
Yes
No
Unknown
2. If yes, was there a positive culture for a bacterial pathogen?
Yes
No
Unknown
3a. If yes, specify Pathogen 1:
/
3b. Date of culture:
3c. Site where pathogen identified:
Blood
Bronchoalveolar lavage (BAL)
Pleural fluid
Other, specify:
/
3d. If Staphylococcus aureus, specify:
Methicillin resistant (MRSA)
4a. If yes, specify Pathogen 2:
Sensitivity unknown
4c. Site where pathogen identified:
/
4b. Date of culture:
Methicillin sensitive (MSSA)
Cerebrospinal fluid (CSF)
Sputum
Endotracheal aspirate
Blood
Bronchoalveolar lavage (BAL)
Pleural fluid
Other, specify:
/
4d. If Staphylococcus aureus, specify:
Methicillin resistant (MRSA)
Methicillin sensitive (MSSA)
Cerebrospinal fluid (CSF)
Sputum
Endotracheal aspirate
Sensitivity unknown
H. Viral Pathogens
1. Was patient tested for any of the following viral respiratory pathogens within 3 days of admission?
Yes
No
1a. Respiratory syncytial virus/RSV
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1b. Adenovirus
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1c. Parainfluenza 1
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1d. Parainfluenza 2
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1e. Parainfluenza 3
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1f. Parainfluenza 4
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1g. Human metapneumovirus
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1h. Rhinovirus/Enterovirus
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1i. Coronavirus (type):
Yes, positive
Yes, negative
Not tested/Unknown
Date:
Unknown
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
I. Influenza Treatment (can record up to 4 treatments in database)
1. Did patient receive antiviral medication treatment for influenza during the course of this illness?
2a. Treatment 1:
Oseltamivir (Tamiflu)
Peramivir (Rapivab)
2b. Method of Administration:
2c. Start Date:
/
Start Date Unknown
3a. Treatment 2:
/
Start Date Unknown
4a. Treatment 3:
Oral
/
Oseltamivir (Tamiflu)
Peramivir (Rapivab)
4b. Method of Administration:
4c. Start Date:
/
Oseltamivir (Tamiflu)
Peramivir (Rapivab)
3b. Method of Administration:
3c. Start Date:
Oral
/
Start Date Unknown
Oral
/
Zanamivir (Relenza)
Other, specify:
Intravenous (IV)
Unknown
Inhaled
/
End Date Unknown
Zanamivir (Relenza)
Other, specify:
Intravenous (IV)
/
End Date Unknown
Zanamivir (Relenza)
Other, specify:
Intravenous (IV)
4d. End Date:
/
End Date Unknown
75 mg
60 mg
QD
QOD
30 mg
3 mg/kg/dose
BID
45 mg
Dose Unknown
Frequency
Unknown
3f. Frequency:
75 mg
60 mg
QD
QOD
30 mg
3 mg/kg/dose
BID
45 mg
Dose Unknown
Frequency
Unknown
/
5. Additional Treatment Comments:
Page 3 of 4
TID
Other
4e. Dose:
Unknown
TID
Other
Other
Unknown
Inhaled
2f. Frequency:
3e. Dose:
Unknown
/
3d. End Date:
Unknown
Other
Unknown
Inhaled
No
2e. Dose:
Unknown
/
2d. End Date:
Yes
4f. Frequency:
75 mg
60 mg
QD
QOD
30 mg
3 mg/kg/dose
BID
45 mg
Dose Unknown
Frequency
Unknown
Other
TID
Other
2017-18 FluSurv-NET Influenza Hospitalization
Surveillance Project Case Report Form
1
Case ID:
7
1
8
J. Chest Radiograph – Based on radiology report only
1. Was a chest x-ray taken within 3 days of admission?
2. Were any of these chest x-rays abnormal?
Yes
No
No
Unknown
2b. For first abnormal chest x-ray, please check all that apply:
Report not available
Air space density
Air space opacity
Bronchopneumonia/pneumonia
Unknown
2a. Date of first abnormal chest x-ray:
/
Yes
/
Cannot rule out pneumonia
Consolidation
Cavitation
ARDS (acute respiratory distress syndrome)
Lung infiltrate
Interstitial infiltrate
Lobar infiltrate
Other
K. Discharge Summary
1. Did the patient have any of the following new diagnoses at discharge? (check all that apply)
No discharge summary available
Bacteremia
Yes
No/Unk
Acute encephalopathy/encephalitis
Yes
No/Unk
Reyes syndrome
Yes
Bronchiolitis
Yes
No/Unk
Acute Myocardial Infarction
Yes
No/Unk
Rhabdomyolysis
Yes
Congestive Heart Failure
Yes
No/Unk
Acute Myocarditis
Yes
No/Unk
Pneumonia
Yes
Sepsis
Yes
COPD exacerbation
Yes
No/Unk
Acute Renal Failure/Acute Kidney Injury
Yes
No/Unk
Seizures
Yes
Diabetic Ketoacidosis
Yes
No/Unk
Acute respiratory distress syndrome (ARDS)
Yes
No/Unk
Stroke
(CVA)
Yes
Guillan-Barre
syndrome
Yes
No/Unk
Acute respiratory failure
Yes
No/Unk
Hemophagocytic syndrome
Yes
No/Unk
Asthma exacerbation
Yes
No/Unk
2. What was the outcome
2a. If discharged alive, please indicate to where:
of the patient?
Private residence
Rehabilitation Facility
Group home/Retirement home
Homeless/Shelter
Jail/Prison
Mental Hospital
Alive
Deceased
Nursing home /Skilled Nursing Facility
Hospice
Unknown
Unknown
Alcohol/Drug Abuse Treatment
Assisted living/Residential care
Other, specify:
Home with services
LTACH
3. If patient was pregnant on admission, indicate pregnancy status at discharge:
Still pregnant
No longer pregnant
Unknown
No/Unk
No/Unk
No/Unk
No/Unk
No/Unk
No/Unk
3a. If patient was pregnant on admission but no longer pregnant at discharge, indicate pregnancy outcome at discharge:
Miscarriage
Ill newborn
Newborn died
Healthy newborn
Abortion
Unknown
4. Additional notes regarding discharge:
L. ICD-10 Discharge Diagnoses – To be recorded in order of appearance
ICD codes
not available
1.
4.
7.
2.
5.
8.
3.
6.
9.
M. Vaccination History
Specify vaccination status and date(s) by source:
1. Medical Chart:
Yes, full date known
1a. If yes, specify dosage date information:
1b. If patient < 9 yrs, specify vaccine type:
/
/
Injected Vaccine
2.Vaccine Registry:
Yes, full date known
2a. If yes, specify dosage date information:
/
2b. If patient < 9 yrs, specify vaccine type:
Injected Vaccine
3. Primary Care Provider /LTCF:
Yes, full date known
3a. If yes, specify dosage date information:
/
3b. If patient < 9 yrs, specify vaccine type:
Injected Vaccine
4. Interview:
Yes, full date known
Patient
Proxy
4a. If yes, specify dosage date information:
/
4b. If patient < 9 yrs, specify vaccine type:
Yes, specific date unknown
Injected Vaccine
No
Date Unknown
Combination of both
Nasal Spray/FluMist
Yes, specific date unknown
/
No
Yes, specific date unknown
/
No
Yes, specific date unknown
No
6. If patient < 9 yrs, did patient receive 2
influenza vaccine in current season?
6a. If yes, specify 2 dosage date information:
nd
/
Yes
/
Unknown
Date Unknown
Combination of both
5. If patient < 9 yrs, did patient receive any seasonal influenza vaccine in previous seasons?
nd
Unknown
Date Unknown
Combination of both
Nasal Spray/FluMist
/
Unknown
Date Unknown
Combination of both
Nasal Spray/FluMist
Nasal Spray/FluMist
Unknown
Yes
No
No
Not Checked
Unsuccessful Attempt
Unknown type
Not Checked
Unsuccessful Attempt
Unknown type
Not Checked
Unsuccessful Attempt
Unknown type
Not Checked
Unsuccessful Attempt
Unknown type
Unknown
Unknown
Date Unknown
N. Miscellaneous
1. Additional Comments:
CDC Rev. 07-2017
Page 4 of 4
CS279597
| File Type | application/pdf |
| File Modified | 2017-11-17 |
| File Created | 2017-08-04 |