Form 0920-1011 National Case Report Form - Standard

Form Approved

OMB # 0920-1011

Exp. 1/31/2020

Lung Injury Associated with E-cigarette Use or Vaping | National Case Report Form – Standard Version

CDC is investigating cases of unexplained lung injury associated with electronic cigarette use or vaping as detailed in CDC’s Health Advisory (https://emergency.cdc.gov/han/han00421.asp). Local and state health departments should complete this form for any probable or confirmed case patient (see case definition) and transmit data to CDC using DCIPHER or by contacting CDC State Points of Contact.

Case ID Number _________________________ Medical Record Number ___________________________________

Case status ☐ Probable ☐ Confirmed Died? ☐ Yes ☐ No If yes, date of death _____________ (see clinical section)

Was patient hospitalized? ☐ Yes ☐ No If yes, hospitalization date __________ Discharge date ________

Date reported to public health department Name of Public Health Department ________________

Person completing form Contact phone number

PART I: PATIENT DEMOGRAPHICS AND EXPOSURES

Patient Demographics

County __________________ State _____________________

Gender ☐Male ☐ Female

Age _________years

Ethnicity ☐Hispanic ☐ Non-Hispanic

Race (Select all that apply) ☐White ☐Black ☐American Indian/Alaska Native ☐Asian ☐Native Hawaiian or Other Pacific Islander

Patient Substance Use in the Past 3 Months (90 days)

Any e-Cigarette use or vaping (e.g., vaping, dabbing)? ☐ Yes ☐ No ☐ Refused to answer

If yes, substance(s) vaped or dabbed in past 3 months?

☐ Nicotine ☐ Marijuana, THC oil, THC concentrates, hash oil, wax ☐ Cannabidiol (CBD) ☐ Synthetic Cannabinoids ☐ Flavors alone

☐ Other substances, specify _____ ☐ Unknown

Any combustible tobacco smoking (i.e. any non-vape nicotine product e.g., cigarettes, cigars)? ☐Yes ☐No Any other tobacco products (e.g., smokeless tobacco)? ☐Yes ☐No

Any combustible marijuana smoking (i.e., any non-vape marijuana)? ☐Yes ☐No Any other marijuana products (e.g., edibles)? ☐Yes ☐No

Nicotine E-cigarette or Vaping Use in the Past 3 Months (90 days)

Any nicotine e-cigarette use or vaping reported? ☐ Yes ☐ No ☐ Unknown Date last used

If yes, what is the frequency of use? ☐ Daily ☐ A few times per week, specify: _________ ☐ A few times per month, specify ______ ☐ Monthly or less

If yes and daily use, on average, how many times per day? __________

Did patient report vaping flavoured nicotine in e-Cigarette and/or vape product(s)? ☐ Yes ☐ No

How many brands of nicotine containing products vaped or dabbed in the past 3 months? _____ [enter whole number]

Where was the nicotine e-Cigarette(s) or vaping product(s) purchased or obtained? Check all that apply

☐ Recreational dispensary ☐ Vape or smoke shop ☐ Pop-up shop ☐ Grocery store/drugstore/Convenience store ☐ Family or friend

☐ Dealer ☐ Online ☐ Other, describe _____________

What kind of device(s) were used with this nicotine product? Select all that apply

☐ Disposable e-cigarette or vaping device ☐ E-cigarettes with pre-filled or refillable cartridges (e.g., using battery pens, Ego, EVO, Ooze

pen, Caliplug, 510 battery) ☐ E-cigarette with tank that you refill with liquids (including sub-ohm, mod or modifiable systems)

☐ E-cigarettes with pre-filled or refillable “pods” or pod cartridges (e.g. JUUL, Suorin) ☐ Other, describe ___________

Were any of these nicotine devices a mod device (a device that allows user to choose higher and/or variable temperatures)? ☐ Yes ☐ No ☐ Unknown

Did patient modify, or add a substance to, the nicotine device(s) that was not intended by the manufacturer? ☐ Yes ☐ No ☐ Unknown

If yes, explain __________________________________________________________________________________

Does patient know anyone else who became ill from vaping nicotine? ☐Yes ☐No

If yes, were nicotine products or devices shared with that person? ☐Yes ☐No

Product sample sent for testing? ☐ Yes ☐ No If yes, where was sample tested _ Product sample ID number(s) __________

THC E-cigarette or Vaping Use in the Past 3 Months (90 days)

Any THC e-cigarette use or vaping reported? ☐ Yes ☐ No ☐ Unknown Date last used

If yes, what is the frequency of use? ☐ Daily ☐ A few times per week, specify: _________ ☐ A few times per month, specify________ ☐ Monthly or less

If yes, on average, how many times per day? __________

Did patient report vaping flavoured THC in e-cigarette and/or vape product(s)? ☐ Yes ☐ No

How many brands of THC containing products vaped or dabbed in the past 3 months? _____ [enter whole number]

What was the purpose of THC product(s) used? ☐ medical purposes ☐ nonmedical (recreational) purposes ☐ other, specify ____

Which THC substance(s) were used in an e-cigarette, vaping device, vaporizer, or dab rig? Select all that apply

☐ Marijuana herb ☐THC oils ☐Butane hash oil ☐THC concentrate (e.g., wax, batter/budder, crumble, shatter, pull and snap)

☐THC powder (e.g., dry sift) ☐ Other, describe ___________

Where was the THC e-cigarette(s) or vaping product(s) purchased or obtained? Check all that apply

☐ Medical dispensary ☐ Recreational dispensary (retail cannabis/marijuana shop) ☐ Vape or smoke shop ☐ Pop-up shop

☐ Grocery store/Drugstore/Convenience store ☐ Family or friend ☐ Illicit dealer ☐ Online ☐ Other, describe __________

What kind of device(s) were used with this substance? Select all that apply

☐ Disposable device ☐ Device with pre-filled cartridges ☐ Device with tank that you refill with liquids (e.g., mods)

☐ Device with pre-filled or refillable “pods” or pod cartridges (e.g. JUUL, Suorin) ☐ Dab rig ☐ Vaporizer (for dry herbs, etc.) ☐ Other ____

What brand of THC cartridge(s) were used with device(s) (Check all that apply): ☐ Rove ☐ Dank Vapes ☐ Golden Gorilla ☐ Smart Cart ☐ Other ____________

Was this a mod device (a device that allows user to choose higher and/or variable temperatures)? ☐ Yes ☐ No ☐ Unknown

Did patient modify, or add a substance to, the device(s) that was not intended by the manufacturer? ☐ Yes ☐ No ☐ Unknown

If yes, explain __________________________________________________________________________________

Does patient know anyone else who became ill from vaping THC? ☐Yes ☐No

If yes, were THC products or devices shared with that person? ☐Yes ☐No

Product sample sent for testing? ☐ Yes ☐ No If yes, where was sample tested _ Product sample ID number(s) ______

PART II: CLINICAL INFORMATION

Symptoms at Initial Presentation to First Encounter to Medical Care

Chief complaint Date symptom(s) started

GI symptoms? ☐ Yes ☐ No ☐ Unknown If yes, describe _________

Respiratory symptoms? ☐ Yes ☐ No ☐ Unknown If yes, describe _________

Constitutional symptoms? ☐ Yes ☐ No ☐ Unknown If yes, describe __________

(e.g., fever, chills, malaise)

Weight loss during current illness? ☐ Yes ☐ No ☐ Unknown If yes, amount (lb)

Medical History

Chronic respiratory disease (including asthma, COPD, etc.)? ☐ Yes ☐ No If yes, specify type of disease

Heart disease? ☐ Yes ☐ No If yes, specify type of disease

Anxiety? ☐ Yes ☐ No

Depression? ☐ Yes ☐ No

Other chronic illness? ☐ Yes ☐ No If yes, specify type of chronic illness

Pregnant? ☐ Yes ☐ No ☐ Unknown If yes, trimester ☐ First ☐ Second ☐ Third ☐ Unknown

Imaging

CT performed ☐ Yes ☐ No If yes, location of abnormal findings ☐ Bilateral ☐ Right ☐ Left ☐ Normal (no findings)

If yes, infiltrates/opacities present ☐ Yes ☐ No Subpleural sparing ☐ Yes ☐ No ☐ Unknown

Chest X-ray performed ☐ Yes ☐ No If yes, location of abnormal findings ☐ Bilateral ☐ Right ☐ Left ☐ Normal (no findings)

If yes, infiltrates/opacities present ☐ Yes ☐ No

Specify other abnormal chest imaging findings (e.g., pneumothorax)_________________

Infectious Disease Testing

Respiratory viral panel ☐ Positive (specify _________ ) ☐ Negative ☐ Pending ☐ Not done

Influenza ☐ Positive (specify _________ ) ☐ Negative ☐ Pending ☐ Not done

Blood cultures ☐ Positive (specify organisms_____) ☐ Negative ☐ Pending ☐ Not done

Legionella urinary antigen ☐ Positive ☐ Negative ☐ Pending ☐ Not done

Strep pneumoniae urinary antigen ☐ Positive ☐ Negative ☐ Pending ☐ Not done

Mycoplasma pneumoniae ☐ Positive (specify _________ ) ☐ Negative ☐ Pending ☐ Not done

Other (Specify)__________________ ☐ Positive (specify _________ ) ☐ Negative ☐ Pending ☐ Not done

Clinical Course of Lung Injury

Is this the first time patient is presenting for medical care for these symptoms? ☐ Yes ☐ No

If yes, is a follow-up visit scheduled? ☐ Yes ☐ No

Was patient hypoxemic (<95) at any outpatient visit or at any point during hospitalization? ☐ Yes ☐ No If yes, date(s)________ Lowest value:_________

Outpatient visit #1 ☐ Yes ☐ No

If yes, date of visit _______

Outpatient visit #2 ☐ Yes ☐ No

If yes, date of visit ______

Were there additional outpatient/clinic visits? ☐ Yes ☐ No

If yes, specify number of additional visits _______

Urgent care visit #1 ☐ Yes ☐ No

If yes, date of visit ____

Urgent care visit #2 ☐ Yes ☐ No

If yes, date of visit _______

Were there additional urgent care visits? ☐ Yes ☐ No

If yes, specify number of additional visits _______

Emergency Department (ED) visit #1 ☐ Yes ☐ No

If yes, date of visit _______

ED visit #2 ☐ Yes ☐ No

If yes, date of visit____

Were there additional ED visits? ☐ Yes ☐ No

If yes, specify number of additional visits _______

If hospitalized, was patient re-hospitalized at a later date? ☐ Yes ☐ No If yes, hospitalization date __________ Discharge date ________

Were there additional hospitalizations? ☐ Yes ☐ No If yes, specify number of additional hospitalizations _______

ICU Admission ☐ Yes ☐ No If yes, ICU admission date _________ ICU duration (in days) __________

Treated with steroids? ☐ Yes ☐ No If yes, medication(s): ________ dose: ____ start date:______ duration: __ ☐ Taper

Treated with antibiotics? ☐ Yes ☐ No If yes, medication(s): ________ dose: ____ start date:______ duration:________

Treated with antivirals? ☐ Yes ☐ No If yes, medication(s): ________ dose: ___ _ start date:______ duration:________

Required respiratory support? ☐ Yes ☐ No ☐ Intubated (duration_________) ☐ BiPAP/CPAP/High flow ☐ Supplemental oxygen

Required ECMO (Extracorporeal membrane oxygenation)? ☐ Yes (duration_________) ☐ No

Clinical specimens

Bronchoalveolar lavage performed? ☐ Yes, date of sample_____ ☐ No If yes, where tested _________________ Specimen ID _______

If yes, lipid staining ☐ Yes ☐ No

If yes, lipid-laden macrophages seen ☐ Yes ☐ No

Blood sample testing performed? ☐ Yes, date of sample ____ ☐ No If yes, where tested _________________ Specimen ID _______

Urine sample testing performed? ☐ Yes, date of sample ____ ☐ No If yes, where tested _________________ Specimen ID _______

Lung biopsy performed? ☐ Yes, date of sample ____ ☐ No If yes, where tested _________________ Specimen ID _______

If yes, lipid staining? ☐ Yes ☐ No

If yes, lipid-laden macrophages seen? ☐ Yes ☐ No

If yes, findings consistent with acute lung injury? ☐ Yes ☐ No If no, specify findings __________________

If yes, other significant findings __________________

Death Information

Died ☐ Yes ☐ No If yes, specify location_______________ Date of death _______________

Immediate cause of death ____________________________ Contributing causes of death ____________________________

Autopsy performed? ☐ Yes ☐ No If yes, autopsy sample collected ☐ Yes ☐ No If yes, where tested______ Specimen ID ________

If yes, lipid staining performed on autopsy lung tissue? ☐ Yes ☐ No If yes, lipid-laden macrophages seen? ☐ Yes ☐ No

If yes, findings consistent with acute lung injury? ☐ Yes ☐ No If no, specify findings _________________

If yes, other significant autopsy findings ___________________

National Case Report Form v.02 Last updated October 31, 201

CDC estimates the average public reporting burden for this collection of information as 60 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1011).