| Label/Short Name |
Description |
Value Set Code |
| CDC Report ID |
CDC assigned report ID. |
(ALPHANUMERIC) |
| CDC Form ID |
CDC assigned form ID. |
(ALPHANUMERIC) |
| State Report ID |
State assigned report ID. |
(ALPHANUMERIC) |
| Human Case ID |
State assigned human case ID. |
(ALPHANUMERIC) |
| Date Created |
The date when the report was created. |
(DATE) |
| General Information: Human Description |
| Sex |
The sex of the human case. |
(SELECT FROM LIST) |
| Age (years) |
The age (in years) of the human case. |
(NUMERIC) |
| State of residence |
The state of residence of the human case. |
(SELECT FROM LIST) |
| General Information: Dates |
| Date of Exposure |
Did the person have an exposure on a single date or multiple dates? |
(SELECT FROM LIST) Single date/Multiple dates/Unknown |
| Date of First Exposure |
When was the first exposure? |
(DATE) |
| Time of First Exposure |
What time did the person have their first exposure? |
(TIME) |
| Date of Last Exposure |
When was the last exposure? |
(DATE) |
| Time of Last Exposure |
What time did the person have their last exposure? |
(TIME) |
| Date of Illness Onset |
When did illness begin? |
(DATE) |
| Time of Illness Onset |
What time did the illness onset begin? |
(TIME) |
| Date of Illness Recovery |
When did illness end? |
(DATE) |
| Time of Illness Recovery |
What time did the illness end? |
(TIME) |
| Date of Death |
When did the patient die? |
(DATE) |
| Time of Death |
What time did the death occur? |
(TIME) |
| Date of Notification to Authorities |
When were State,Territories,Local, or Tribal Health Authorities notified? |
(DATE) |
| Date of Interview |
When did the interview occur? |
(DATE) |
| Time of Interview |
What time did the interview occur? |
(TIME) |
| Date Remarks |
Additional information regarding date(s). |
(FREE TEXT) |
| Human Exposure Information: Exposure Description |
| Exposure State(s) |
What state the did the exposure occur in? |
(MULTISELECT) |
| Exposure Count(ies) |
What county the did the exposure occur in? |
(MULTISELECT) |
| Exposure Setting(s) |
What setting the did the exposure occur in? |
(MULTISELECT) e.g. State Park/Private Residence |
| Specific Location Name(s) |
What is the specific name of the location where the exposure occured? |
(FREE TEXT) e.g. Cook's beach |
| Exposure Source |
What medium was the exposure source? |
(SELECT FROM LIST) e.g. Food/Water/Air/Other/Unknown |
| Exposure Activity |
What activities may have been associated with exposure? |
(SELECT FROM LIST) e.g. Recreation activities/Personal use/Commerical agriculture/Farming/Non-personal use/Aquaculture/Other/None/Unknown |
| Exposure Activity Description |
Description of exposure activity. |
(FREE TEXT) |
| Water Type |
Type of water body if applicable. |
(SELECT FROM LIST) e.g. Lake/Beach/Community water system/Other/Unknown |
| Food Type |
Type of food if applicable. |
(SELECT FROM LIST) e.g. Shellfish/Mussels/Finfish/Other/Unknown |
| Activity Duration |
How long did the activity last? |
(NUMERIC) |
| Activity Duration Unit |
What was the unit of time of the activity? |
(SELECT FROM LIST) Minutes/Hours/Days |
| Routes of Exposure |
What were the routes of exposure? |
(MULTISELECT) e.g. Ingestion/Inhalation/Skin Contact/Other/Unknown |
| Exposure Remarks |
Any additional information regarding the exposure(s)? |
(FREE TEXT) |
| Illness and Health Outcomes: Signs and Symptoms of Illness |
| Signs or symptoms |
What signs or symptoms of illness were experienced? |
(SELECT FROM LIST) e.g Lethargy/Ear Discharge/Rash/Other/Unknown |
| Time to Onset |
What was the time to illness onset? |
(NUMERIC) |
| Onset Unit |
What was the unit of time? |
(SELECT FROM LIST) Minutes/Hours/Days |
|
|
|
| Duration of Symptoms |
How long did the symptom(s) last? |
(NUMERIC) |
| Duration Unit |
What is the unit of time? |
(SELECT FROM LIST) Minutes/Hours/Days |
| Recurrence Following Mutiple Exposures |
Did the symptom reoccur after secondary, tertiary, etc exposures? |
Yes No Unknown (YNU) |
| Signs/Symptoms Consistent with Exposure |
Was the sign/symptom consistent with the route of exposure? |
Yes No Unknown (YNU) |
| Signs/Symptoms Consistent with Food Item |
If food was implicated, were the signs/symptoms consistent with foodborne fish/shellfish poisoning? |
Yes No Unknown (YNU) |
| Poisoning Description |
Characterization of foodborne poisoning symptoms. |
(SELECT FROM LIST) e.g. PSP/Ciguatera/Other |
| Signs/Symptoms Remarks |
Additional comments for signs/symptoms. |
(FREE TEXT) |
| Illness and Health Outcomes: Medical Care and Health Outcomes |
| Care from Non-medical Provider |
Did the person receive first aid care from a non-medical provider? |
Yes No Unknown (YNU) |
| Healthcare Visit |
Did the person visit a healthcare provider? |
Yes No Unknown (YNU) |
| Emergency Department Visit |
Did the person go to an emergency department? |
Yes No Unknown (YNU) |
| Poison Control Contact |
Was a poison control center contacted? |
Yes No Unknown (YNU) |
| Death |
Did the person die? |
Yes No Unknown (YNU) |
| Additional Medical/Health Outcome Information |
Do you have additional information about medical care or health outcomes for this person? |
Yes No Indicator (HL7) |
| Medical Care and Health Outcome Remarks |
Additional comments for medical care and health outcomes. |
(FREE TEXT) |
| Illness and Health Outcomes: Health History and Differential Diagnosis |
| Chronic Respiratory Disease |
Does the person have a history of chronic respiratory disease e.g. asthma, COPD? |
Yes No Unknown (YNU) |
| Tobacco Use |
Does the person have a history of tobacco use? |
Yes No Unknown (YNU) |
| Chronic Skin Disease |
Does the person have a history of skin disease e.g. psoriasis, eczema? |
Yes No Unknown (YNU) |
| Allergies |
Does this person have a history of allergies to food, medication, or other substances? |
Yes No Unknown (YNU) |
| Chronic Gastrointestinal Disease |
Does this person have a history of chronic gastrointestinal disease e.g. Crohn's disease? |
Yes No Unknown (YNU) |
| Chronic Kidney Disease |
Does this person have a history of chronic kidney disease e.g. caused by hypertension, diabetes, extended use of NSAIDs? |
Yes No Unknown (YNU) |
| Liver Disease |
Does this person have a history of liver disease e.g. hepatitis or cirrhosis? |
Yes No Unknown (YNU) |
| Chronic Neurologic Diseased |
Does this person have a history of chronic neurologic disease e.g. caused by diabetes? |
Yes No Unknown (YNU) |
| Immunocompromised |
Was the person immunocompromised due to medication or illness e.g. transplant recipient, diabetic? |
Yes No Unknown (YNU) |
| Alcohol Consumption within 24 Hours |
Did the person drink any alcohol within 24 hours prior to symptoms? |
Yes No Unknown (YNU) |
| Pregnant |
Was the person pregnant? |
|
| Skin Sensitivity due to Medication |
Was the person taking medications that increased skin sensitivity to the sun e.g. acne treatment, antibiotics? |
Yes No Unknown (YNU) |
| OTC Pain Medication |
Did the person frequently take over the counter (OTC) pain medication e.g. more than 5 times a week? |
Yes No Unknown (YNU) |
| Open Wounds |
Did the person have an open wound, sores, or broken skin at th etime of exposure? |
Yes No Unknown (YNU) |
| Communicable Diseases |
Had the person recently been exposed to any communicable diseases that cause similar signs or symptoms? |
Yes No Unknown (YNU) |
| Environmental Irritants |
Had the person recently been exposed to any environmental irritants that cause similar signs or symptoms e.g. poison ivy/oak? |
Yes No Unknown (YNU) |
|
|
|
| Other Causes Investigated |
Were other causes of the illness investigated? |
Yes No Unknown (YNU) |
| Other Environmental Sample Testing |
Were environmental samples tested to rule out other possible causes e.g. mushrooms? |
Yes No Unknown (YNU) |
| Clinical Testing |
| Clinical Specimen Testing |
Were clinical specimens tested? |
Yes No Unknown (YNU) |
| Type of Clinical Testing |
What type of clinical testing was performed to diagnose the illness or rule out other causes? |
(MULTISELECT) e.g. Bloodwork/Culture/Fecal analysis/Histopathology/Skin biopsy/Stomach content analysis/Toxicology/Urinalysis/X-ray/Other/Unknown |
| Classification |
What broad category of pathogen/toxin does the test result fall within? |
(SELECT FROM LIST) |
| Genus or Toxin |
What is the genus or toxin name? |
(SELECT FROM LIST) |
| Species |
What is the species name? |
(SELECT FROM LIST) |
| Subspecies/Serotype/Genotype |
What is the subspecies, serotype, or genotype? |
(SELECT FROM LIST) |
| Specimen Detection |
What type of clinical specimen tested positive? |
(SELECT FROM LIST) e.g. Blood/Stool/Tissue/Stomach Contents/Other |
| Concentration |
What was the concentration of the test result? |
(NUMERIC) |
| Concentration Unit |
What is the test result unit of concentration? |
(SELECT FROM LIST) |
| Test Type |
What was the type of test that was performed? |
(SELECT FROM LIST) |
| Clinical Testing Remarks |
Additional remarks regarding clinical testing? |
(FREE TEXT) |
| Supplemental Information |
| General Remarks |
Additional remarks regarding the human case. |
(FREE TEXT) |
| Attachments |
Additional attachments regarding the human case. |
(UPLOAD) e.g. word document,excel spreadsheet, image |
| Report Administration |
| Report Author |
Who is the author of the report? |
(FREE TEXT) |
| Form Author |
Who is the author of the form? |
(FREE TEXT) |
| Reporting Site Name |
What is the name of the reporting site? |
(FREE TEXT) |
| Agency Name |
What is the name of the agency? |
(FREE TEXT) |
| Agency Contact Name |
Who is the agency contact? |
(FREE TEXT) |
| Agency Contact Title |
What is the agency contact's title? |
(FREE TEXT) |
| Agency Contact Phone |
What is the agency contact's phone number? |
(FREE TEXT) |
| Agency Contact Fax |
What is the agency contact's fax number? |
(FREE TEXT) |
| Agency Contact Email |
What is the agency contact's email address? |
(FREE TEXT) |
| Label/Short Name |
Description |
Value Set Code |
| CDC Report ID |
CDC assigned report ID. |
(ALPHANUMERIC) |
| CDC Form ID |
CDC assigned form ID. |
(ALPHANUMERIC) |
| State Report ID |
State assigned report ID. |
(ALPHANUMERIC) |
| Human Case ID |
State assigned human case ID. |
(ALPHANUMERIC) |
| Date Created |
The date when the report was created. |
(DATE) |
| General Information: Animal Description |
| Animal Category |
What is the category of animal(s) being reported? |
(SELECT FROM LIST) e.g. Domestic pet/Livestock/Wildlife/Other/Unknown |
| Animal Type |
What type of animal(s) are you reporting? |
(SELECT FROM LIST) Animal Type (FDD) |
| Animal Desciption |
Additional animal(s) description. |
(FREE TEXT) e.g. dog breed, cat breed, type of bird, amphibian, reptile, other, or other mammal |
| Single/Group of Animal(s) |
Does this illness report describe a single animal or a groupof animals e.g. school of fish, flocks, herds? |
(SELECT ONE) Single Animal/Group of Animals |
| Single Animal Age |
What is the age of the animal? |
(NUMERIC) |
| Single Animal Weight |
What is the weight of the animal (kg/lb)? |
(NUMERIC) |
| Single Animal Death |
Did the animal die? |
Yes No Unknown (YNU) |
| Single Animal Condition |
What condition was the animal found in? |
(MULTISELECT) e.g. Alive/Fresh/Scavenged/Decomposed/Unknown/Not applicable |
| Group Animals Affected |
How many animals were affected? |
(NUMERIC) |
| Group Animal Deaths |
Did any animals die? |
Yes No Unknown (YNU) |
| Group Animal Death Count |
How many dead animals were counted? |
(NUMERIC) |
| Group Animal Condition |
What condition were the animals found in? |
(MULTISELECT) e.g. Alive/Fresh/Scavenged/Decomposed/Unknown/Not applicable |
| General Information: Dates |
| Date of Exposure |
Did the person have an exposure on a single date or multiple dates? |
(SELECT FROM LIST) Single date/Multiple dates/Unknown |
| Date of First Exposure |
When was the first exposure? |
(DATE) |
| Time of First Exposure |
What time did the first exposure occur? |
(TIME) AM/PM |
| Date of Last Exposure |
When was the last exposure? |
(DATE) |
| Time of Last Exposure |
What time did the last exposure occur? |
(TIME) AM/PM |
| Date of Discovery |
When was the animal discovered? |
(DATE) |
| Time of Discovery |
What time was the animal discovered? |
(TIME) AM/PM |
| Date of Illness Onset |
When did the illness begin? |
(DATE) |
| Time of Illness Onset |
What time did the illness begin? |
(TIME) AM/PM |
| Date of Death |
When did the animal(s) die? |
(DATE) |
| Time of Death |
What time did the animal(s) die? |
(TIME) AM/PM |
| Date of Notification to Authorities |
When were State,Territories,Local, or Tribal Health Authorities notified? |
(DATE) |
| Date Remarks |
Additional remarks regarding the date. |
(FREE TEXT) |
| Animal Exposure Information: Exposure Description |
| Exposure State(s) |
What state did the exposure occur in? |
(MULTISELECT) |
| Exposure Count(ies) |
What county did the exposure occur in? |
(MULTISELECT) |
| Exposure Setting(s) |
What setting did the exposure occur in? |
(MULTISELECT) e.g. State Park/National Park/Private Residence |
| Specific location name(s) |
What is the specific name of the location where the exposure occurred? |
(FREE TEXT) e.g. Cook's beach |
| Exposure Source |
What medium was the exposure source? |
(SELECT FROM LIST) e.g. Food/Water/Air/Other/Unknown |
| Exposure Activity |
What activities may have been associated with exposure? |
(SELECT FROM LIST) e.g. Recreation activites/Swimming/Other/None/Unknown |
| Water Type |
Type of water body if applicable. |
(SELECT FROM LIST) e.g. Lake/Beach/Community water system/Other/Unknown |
| Food Type |
Type of food if applicable. |
(SELECT FROM LIST) e.g. Shellfish/Mussels/Finfish/Other/Unknown |
| Activity Duration |
How long did the activity last? |
(FREE TEXT) |
| Activity Duration Unit |
Unit of the time. |
(Minutes/Hours/Days) |
| Routes of Exposure |
What were the routes of exposure? |
(MULTISELECT) e.g. Ingestion/Inhalation/Skin Contact/Other/Unknown |
|
|
|
|
|
|
| Exposure Remarks |
Any additional information regarding the exposure(s)? |
(FREE TEXT) |
| Signs of Illness and Health Outcomes: Signs of Illness |
| Signs |
What signs of illness were observed? |
(SELECT FROM LIST) e.g. Lethargy/Ear Discharge/Rash/Other/Unknown |
| Time to Onset |
What was the time to illness onset? |
(NUMERIC) |
| Onset Unit |
What was the unit of time? |
(SELECT FROM LIST) Minutes/Hours/Days |
| Duration of Signs |
How long did the sign(s) last? |
(NUMERIC) |
| Duration Unit |
What is the unit of time? |
(SELECT FROM LIST) Minutes/Hours/Days |
| Recurrence Following Mutiple Exposures |
Did the sign reoccur after secondary, tertiary, etc exposures? |
Yes No Unknown (YNU) |
| Signs Consistent with Exposure |
Was the sign consistent with the route of exposure? |
Yes No Unknown (YNU) |
| Signs of Illness and Health Outcomes: Medical Care and Health Outcomes |
| Veterinary Treatment |
Did the animal(s) receive veterinary medical care or treatment? |
Yes No Unknown (YNU) |
| Veterinary Admission |
Did the animal(s) get admitted to a veterinary facility? |
Yes No Unknown (YNU) |
| Additional Medical/Health Outcome Information |
Do you have additional information about medical care or health outcomes for the animal(s)? |
Yes No Indicator (HL7) |
| Medical Care and Health Outcome Remarks |
Additional information regarding the animal(s) medical care and health outcome. |
(FREE TEXT) |
| Signs of Illness and Health Outcomes: Health History and Differential Diagnosis |
| Pre-existing Conditions |
Did the animal(s) have any pre-existing conditions or disabilities? |
Yes No Unknown (YNU) |
| Medications |
Did the animal(s) receive any medications in the month before illness onset? |
Yes No Unknown (YNU) |
| Other Causes Investigated |
Were other causes of illness investigated? |
Yes No Unknown (YNU) |
| Other Environmental Sample Testing |
Were environmental samples tested to rule out other possible causes e.g. mushrooms? |
Yes No Unknown (YNU) |
| Health History and Differential Diagnosis Remarks |
Additional remarks regarding the animal(s) health history and differential diagnosis. |
(FREE TEXT) |
| Clinical Testing |
| Clinical Specimen Testing |
Were clinical specimens tested? |
Yes No Unknown (YNU) |
| Type of Clinical Testing |
What type of clinical testing was performed to diagnose the illness or rule out other causes? |
(MULTISELECT) e.g. Bloodwork/Culture/Fecal analysis/Histopathology/Skin biopsy/Stomach content analysis/Toxicology/Urinalysis/X-ray/Other/Unknown |
| Classification |
What broad category of pathogen/toxin does the test result fall within? |
(SELECT FROM LIST) |
| Genus or Toxin |
What is the genus or toxin name? |
(SELECT FROM LIST) |
| Species |
What is the species name? |
(SELECT FROM LIST) |
| Subspecies/Serotype/Genotype |
What is the subspecies, serotype, or genotype? |
(SELECT FROM LIST) |
| Specimen Detection |
What type of clinical specimen tested positive? |
(SELECT FROM LIST) e.g. Blood/Stool/Tissue/Stomach Contents/Other |
| Concentration |
What was the concentration of the test result? |
(NUMERIC) |
| Concentration Unit |
What is the test result unit of concentration? |
(SELECT FROM LIST) |
| Test Type |
What was the type of test that was performed? |
(SELECT FROM LIST) |
| Clinical Testing Remarks |
Additional remarks regarding clinical testing? |
(FREE TEXT) |
| Supplemental Information |
| General Remarks |
Additional remarks regarding the animal case. |
(FREE TEXT) |
| Attachments |
Additional attachments regarding the animal case. |
(UPLOAD) e.g. word document,excel spreadsheet, image |
| Report Administration |
| Report Author |
Who is the author of the report? |
(FREE TEXT) |
| Form Author |
Who is the author of the form? |
(FREE TEXT) |
| Reporting Site Name |
What is the name of the reporting site? |
(FREE TEXT) |
|
|
|
|
|
|
| Agency Name |
What is the name of the agency? |
(FREE TEXT) |
| Agency Contact Name |
Who is the agency contact? |
(FREE TEXT) |
| Agency Contact Title |
What is the agency contact's title? |
(FREE TEXT) |
| Agency Contact Phone |
What is the agency contact's phone number? |
(FREE TEXT) |
| Agency Contact Fax |
What is the agency contact's fax number? |
(FREE TEXT) |
| Agency Contact Email |
What is the agency contact's email address? |
(FREE TEXT) |
| Label/Short Name |
Description |
Value Set Code |
| CDC Report ID |
CDC assigned report ID. |
(ALPHANUMERIC) |
| CDC Form ID |
CDC assigned form ID. |
(ALPHANUMERIC) |
| State Report ID |
State assigned animal case ID. |
(ALPHANUMERIC) |
| Date Created |
The date when the report was created. |
(DATE) |
| General Information: Dates |
| Date of First Bloom |
When was the bloom first observed? |
(DATE) |
| Other Event |
Reason for report, if no date of first bloom. |
(SELECT FROM LIST) e.g. Foodborne intoxication/Other evidence of Harmful algal toxicity |
| Date of Notification to Authorities |
When were State,Territories,Local, or Tribal Health Authorities notified? |
(DATE) |
| Date Remarks |
Additional information regarding dates. |
(FREE TEXT) |
| General Information: Geographic Description |
| State/Jurisdiction |
What state(s)/jurisdiction(s) did the event occur in? |
(SELECT FROM LIST) |
| Count(ies) |
What count(ies) did the event occur in? |
(MULTISELECT) |
| Other States Affected |
Did an algal bloom impact water quality in any other states? |
Yes No Unknown Not applicable |
| Other States |
What other states were affected? |
(SELECT FROM LIST) |
| Official Name of Water Body |
What is the official name of the water body? |
(FREE TEXT) |
| Common Name of Water Body |
What is the common name of the water body? |
(FREE TEXT) |
| Specific Location Name(s) |
What is the specific name of the location? |
(FREE TEXT) e.g. Cook's beach |
| Nearest City/Town |
What is the nearest City/Town? |
(FREE TEXT) |
| Coordinate Format |
What is the format of the location coordiantes? |
(SELECT FROM LIST) e.g., Degrees Minutes Seconds/Decimal Degrees |
| Latititude |
What is the latitude of the event? |
(NUMERIC) |
| Longitude |
What is the longitude of the event? |
(NUMERIC) |
| Hydrologic Unit Code |
What is the hydrologic unit code? |
(MULTISELECT) |
|
|
|
|
|
|
| Water Type |
What water type did the event occur in? What was the type of water body? |
(SELECT FROM LIST) |
| Water Salinity |
What salinity was the water body? |
(SELECT FROM LIST) e.g. Fresh/Brackish/Salt |
| Water Body of Bloom |
What is the water body, or if applicable, the area of the water body where the bloom was located, used for? |
(MULTISELECT) e.g. Agriculture/Aquaculture/Industrial-Occupational/Public drinking water system/Raw water, non-potable/Recreation/Other/None/Unknown |
| Geographic Description Remarks |
Additional information regarding geographic description. |
(FREE TEXT) |
| Bloom Description: Health Advisories/Warnings |
| Type of Advisory/Warning |
If an advisory/warning was issued, what was type of advisory/warning? |
(SELECT FROM LIST) e.g. Health advisory/No contact warning/Water body closure (recreational activity)/Water body closure (fish/shellfish)/Other |
| Advisory/Warning Response |
Was there a response issued for the type of advisory/warning? |
Yes No Unknown Not applicable |
| Advisory/Warning Agency |
What agency if applicable issued the advisory/warning? |
(FREE TEXT) |
| Advisory Criteria/Reason |
What criteria/reason was the advisory issued for? |
(FREE TEXT) |
| Advisory/Warning Start Date |
What date did the advisory/warning begin? |
(DATE) |
| Advisory/Warning End Date |
What date did the advisory/warning end? |
(DATE) |
| Bloom Description: Observational Data |
| Date Documented |
What day did the event occur? |
(DATE) |
| Documented By |
Who documented the event? |
(FREE TEXT) |
| Scum/Algal Matter Observed |
Was any scum or algal matter observed? |
Yes No Unknown (YNU) |
| Water Color |
What color was the water? |
(SELECT FROM LIST) e.g. Red/Yellow/Green |
| Water Clarity |
What was the water clarity? |
(SELECT FROM LIST) e.g. Clear/Muddy |
| Water Odors |
Did the water have an odor? |
Yes No Unknown (YNU) |
| Water Flow |
Was there water flow? |
(SELECT FROM LIST) Moving/Stagnant/Unknown |
| Tidal Conditions |
Were there tidal conditions? |
(SELECT FROM LIST) High tide/Low Tide/Not applicable |
|
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|
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|
|
|
|
|
| Laboratory Testing: Algae, Algal Toxins or Components Testing |
| Samples Tested |
What was tested for algae, algal toxins or components? |
(MULTISELECT) e.g. Air/Algae/Finished drinking water/Food/Raw water, ambient/No testing/Other/Unknown |
| Reason Samples Tested |
If testing was conducted, why was it tested? |
(MULTISELECT) e.g. Fish illness,kill/Animal health event response/Citizen complaint/Human health event response/Monitoring/Odor/Other/Unknown |
| Water Testing |
If water testing was performed, were any of the following tests conducted? |
(MULTISELECT) e.g. Algae/Algal toxins/Chlorophyll/Copper sulfate/Enterococci/Fecal coliforms/Other |
| Laboratory Testing: Laboratory Results |
| Classification |
What broad category of pathogen/toxin does the test result fall within? |
(SELECT FROM LIST) |
| Genus or Toxin |
What is the genus or toxin name? |
(SELECT FROM LIST) |
| Species |
What is the species name? |
(SELECT FROM LIST) |
| Subspecies |
What is the subspecies? |
(SELECT FROM LIST) |
| Sample Detection |
What type of environmental sample tested positive? |
(SELECT FROM LIST) e.g. Blood/Stool/Tissue/Stomach Contents/Other |
| Sample Description |
Description of the environmental sample that tested postitive. |
(FREE TEXT) |
| Concentration |
What was the concentration of the test result? |
(NUMERIC) |
| Concentration Unit |
What was the test result unit of concentration? |
(SELECT FROM LIST) |
| Test Type |
What was the type of test that was performed? |
(SELECT FROM LIST) |
| Sample Collection Date |
What date were the samples collected? |
(DATE) |
| Sample Collection Time |
What time were the samples collected? |
(TIME) |
| Laboratory Testing Remarks |
Additional remarks regarding laboratory testing? |
(FREE TEXT) |
| Links to Other Systems: Links to Other Data Systems Containing Information About the Bloom |
| System Type |
What the type of system? |
(SELECT FROM LIST) Federal/State |
| System Name |
What is the system name? |
(SELECT FROM LIST) e.g. NPS HAB surveillance/NORS |
|
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|
|
|
|
|
| System Report ID Number |
What is the system report ID number? |
(FREE TEXT) |
| Brief Description of Linked Information |
Descripton of linked information. |
(FREE TEXT) |
| Supplemental Information |
| General Remarks |
Additional remarks regarding the environmental event. |
(FREE TEXT) |
| Attachments |
Additional attachments regarding the environmental event. |
(UPLOAD) e.g. word document,excel spreadsheet, image |
| Report Administration |
| Report Author |
Who is the author of the report? |
(FREE TEXT) |
| Reporting Site Name |
What is the name of the reporting site? |
(FREE TEXT) |
| Agency Name |
What is the name of the agency? |
(FREE TEXT) |
| Agency Contact Name |
Who is the agency contact? |
(FREE TEXT) |
| Agency Contact Title |
What is the agency contact's title? |
(FREE TEXT) |
| Agency Contact Phone |
What is the agency contact's phone number? |
(FREE TEXT) |
| Agency Contact Fax |
What is the agency contact's fax number? |
(FREE TEXT) |
| Agency Contact Email |
What is the agency contact's email address? |
(FREE TEXT) |
| Label/Short Name |
Description |
Value Set Code |
| Environmental Form |
| HAB Event Definition |
Definition of HAB event |
(SELECT FROM LIST) Suspect/Probable/Confirmed |
| Laboratory-based HAB data |
Laboratory detection of cyanobacteria, other potentially toxin-producing algae, or algal/cyanobacterial toxins in a water body or finished drinking water supply |
(SELECT FROM LIST) Yes/No/Unknown |
| Observational or environmental data |
Observational or environmental data from a water body to support the presence of an algal bloom |
(SELECT FROM LIST) Yes/No/Unknown |
| Associated illness |
Any associated illness |
(SELECT FROM LIST) Yes/No/Unknown |
| Event Definition Comments |
Any other comments that may contribute to the event definition |
(ALPHANUMERIC) |
| Human Form |
| Human Case Definition |
Definition of a human HAB-associated case |
(SELECT FROM LIST) Suspect/Probable/Confirmed |
| Exposure |
Exposure to water, algae, or seafood, dietary supplements |
(SELECT FROM LIST) Yes/No/Unknown |
| Signs/Symptoms |
Self-reported signs/symptoms after exposure |
(SELECT FROM LIST) Yes/No/Unknown |
| Public Health Assessment |
Public health assessment is defined as the action of compiling all data available and deciding that the illness in question is likely HAB-related |
(SELECT FROM LIST) Yes/No/Unknown |
| Professional medical diagnosis |
Professional medical diagnosis being provided by a medical practitioner based on his or her medical assessment of the patient's symptoms, medical history, exposure, etc. |
(SELECT FROM LIST) Yes/No/Unknown |
| Other causes of illness ruled out |
Other causes of illness ruled out |
(SELECT FROM LIST) Yes/No/Unknown |
| Observational or environmental data |
Observational or environmental data from a water body to support the presence of an algal bloom |
(SELECT FROM LIST) Yes/No/Unknown |
| Laboratory-based HAB data |
Laboratory detection of cyanobacteria, other potentially toxin-producing algae, or algal/cyanobacterial toxins in a water body or finished drinking water supply, seafood or dietary supplements |
(SELECT FROM LIST) Yes/No/Unknown |
| Clinical data |
Laboratory documentation of cyanobacteria, other potentially toxin-producing algae, or algal/cyanobacterial toxins in a clinical specimen |
(SELECT FROM LIST) Yes/No/Unknown |
| Human Case Definition Comments |
Any comments that may contribute to the human case definition |
(ALPHANUMERIC) |
| Animal Form |
| Animal Case Definition |
Definition of an animal HAB-associated case |
(SELECT FROM LIST) Suspect/Probable/Confirmed |
| Exposure |
Exposure to water, algae, or other dietary HAB sources. This includes undocumented exposures that are suspected based on temporal or spatial factors or an animal's opportunity for exposure due to biological, behavioral, or other relevant factors |
(SELECT FROM LIST) Yes/No/Unknown |
| Signs/Symptoms |
Reported signs after exposure, including the outcome of death prior to discovery |
(SELECT FROM LIST) Yes/No/Unknown |
| Public Health Assessment |
Public health assessment is defined as the action of compiling all data available and deciding that the illness in question is likely HAB-related. Assessments may also be completed by qualified non-public health entities that have been identified by State or Federal agency partners |
(SELECT FROM LIST) Yes/No/Unknown |
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| Professional medical diagnosis |
Professional medical diagnosis being provided by a medical practitioner based on his or her medical assessment of the animal's signs, medical history, likelihood of exposure, etc. |
(SELECT FROM LIST) Yes/No/Unknown |
| Other causes of illness ruled out |
Other causes of illness ruled out |
(SELECT FROM LIST) Yes/No/Unknown |
| Observational or environmental data |
Observational or environmental data from a water body to identify an algal bloom |
(SELECT FROM LIST) Yes/No/Unknown |
| Laboratory-based HAB data |
Laboratory detection of cyanobacteria or other potentially toxin-producing algae or algal/cyanobacterial toxins in a water body, finished drinking water supply, or animal dietary sources |
(SELECT FROM LIST) Yes/No/Unknown |
| Clinical data |
Laboratory documentaion of cyaanobacteria, other potentially toxin-producing algae, or algal/cyanobacterial toxinsin a clinical specimen |
(SELECT FROM LIST) Yes/No/Unknown |
| Animal Case Definition Comments |
Any comments that may contribute to the human case definition |
(ALPHANUMERIC) |