Form 0920-0978 2019-2020 FluSurv-NET Influenza Hospitalization Surveill

2019-20 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 30329

1

Case ID:

9

2

Form Approved
OMB No. 0920-0978

0
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:
1. Case Classification:
Prospective Surveillance
6. Date of Birth:

/

Discharge Audit
7. Age:

Hispanic or Latino

2. Admission Type:
Hospitalization

Years

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. Date of Abstraction:
C. Enrollment Information

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:

14. Where did patient reside at the time of hospitalization? (Indicate TYPE of residence.)
Private residence
Hospice
Assisted living/Residential care
Home with Services
LTACH
Homeless/Shelter
Group home/Retirement
Nursing home/Skilled Nursing Facility
Psychiatric facility
Alcohol/Drug Abuse Treatment
Unknown
Hospitalized at birth
Other long term care facility
Rehabilitation facility

Adult

/

15. Type of Insurance:

Corrections Facility
Other, specify:
14a. If resident of a facility, indicate NAME of facility:

No

/

13b. Transfer Hospital Admission Date:
13c. Transfer Date:

Yes

Unknown

/

/

(Check all that apply):

Private
Medicare
Medicaid/state assistance program
Military
Indian Health Service

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
3c. Testing facility ID:

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)

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 17 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 5

2019-20 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form (CDC Rev. 07-2019)

CS309329

2019-20 FluSurv-NET Influenza Hospitalization
Surveillance Project Case Report Form

1

Case ID:

9

2

0

E. Admission and Patient History
1. Acute signs/symptoms present at admission (began or worsened within 2 weeks prior to admission):
Non-respiratory symptoms

Respiratory symptoms

Altered mental status/confusion
Fever/chills
Seizures

Congested/runny nose
Cough

Shortness of breath/respiratory distress
Sore throat

/

2. Date of onset of acute respiratory symptoms (within 2 weeks before a positive flu test):
3. BMI:

4. Height:

Unk

In

No Signs/Symptoms

5. Weight:
Cm

Unk

Lbs

Kg

Unk

/

6. Smoker (tobacco):
Former
Current

Unknown

7. Alcohol abuse:
Current

Former

No/Unk

No/Unk

URI/ILI
Wheezing
Not applicable

8. Substance abuse:
Current

Former

No/Unk

8a. Substance Abuse Type (current use only) (check all that apply):
IVDU

Opioids

Cocaine

9. Current Non-Tobacco Smoker:

Methamphetamines
Yes

No/Unknown

Marijuana (ingested or unknown route)
(check all that apply):

Marijuana

10. Did patient have any of the following pre-existing medical conditions? Check all that apply.
10a. Asthma/Reactive Airway Disease
Yes
No/Unknown
10b. Chronic Lung Disease
Yes
No/Unknown
Active tuberculosis/TB
Asbestosis
Bronchiectasis
Bronchiolitis obliterans
Chronic bronchitis
Chronic respiratory failure
Cystic fibrosis (CF)
Emphysema/Chronic obstructive pulmonary disease (COPD)
Interstitial lung disease (ILD)
Oxygen (O2) dependent
Obstructive sleep apnea (OSA)
Pulmonary fibrosis
Restrictive lung disease
Sarcoidosis
Other, specify:
10c. Chronic Metabolic Disease
Yes
No/Unknown
Adrenal Disorders (Addison’s, Adrenal insufficiency, Cushing syndrome,
Congenital adrenal hyperplasia)
Diabetes mellitus (DM)
Glycogen or other storage diseases (see list)
Hyper/Hypo function of pituitary gland
Inborn errors of metabolism (see list)
Metabolic syndrome
Parathyroid dysfunction (Hyperparathyroidism, Hypoparathyroidism)
Thyroid dysfunction (Grave’s disease, Hashimoto’s disease,
Hyperthyroidism, Hypothyroidism)
Other, specify:
10d.Blood Disorders/Hemoglobinopathy
Yes
No/Unknown
Alpha thalassemia
Aplastic anemia
Beta thalassemia
Coagulopathy (Factor V Leiden, Von Willebrand disease (VWD), see list)
Hemoglobin S-beta thalassemia
Leukopenia
Myelodysplastic syndrome (MDS)
Neutropenia
Pancytopenia
Polycythemia vera
Sickle cell disease
Splenectomy/Asplenia
Thrombocytopenia
Other, specify:

Page 2 of 5

Other, specify:

E-nicotine delivery system (ENDS)
Yes

No

Unknown
Other

Unknown

10e. Cardiovascular Disease
Yes
No/Unknown
Aortic aneurysm (AAA), history of
Aortic regurgitation (AR)
Aortic stenosis (AS)
Atherosclerotic cardiovascular disease (ASCVD)
Atrial fibrillation (AFib)
Atrioventricular (AV) blocks
Automated implantable devices (AID/AICD)/Pacemaker
Bundle branch block (BBB/RBBB/LBBB)
Cardiomyopathy
Carotid stenosis
Cerebral vascular accident (CVA)/Incident/Stroke , history of
Congenital heart disease (Specify)
Atrial septal defect
Pulmonic stenosis
Tetralogy of Fallot
Ventricular septal defect
Other, specify:
Coronary artery bypass grafting (CABG), history of
Coronary artery disease (CAD)
Deep vein thrombosis (DVT), history of
Heart failure/Congestive heart failure (CHF)
Myocardial infarction (MI), history of
Mitral stenosis (MS)
Mitral regurgitation (MR)
Peripheral artery disease (PAD)
Peripheral vascular disease (PVD)
Pulmonary embolism (PE), history of
Pulmonary hypertension (PHTN)
Pulmonic stenosis
Pulmonic regurgitation
Transient ischemic attack (TIA) , history of
Tricuspid stenosis
Tricuspid regurgitation (TR)
Aortic/Mitral/Tricuspid/Pulmonic valve replacement , history of
Ventricular tachycardia (VT, VTach) , history of
Ventricular fibrillation (VF, VFib) , history of
Other, specify:
10f. Neuromuscular Disorder
Yes
No/Unknown
Amyotrophic lateral sclerosis (ALS)
Mitochondrial disorder (see list)
Multiple sclerosis (MS)
Muscular dystrophy (see list)
Myasthenia gravis (MG)
Parkinson’s disease
Scoliosis/Kyphoscoliosis
Other, specify:

2019-20 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form (CDC Rev. 07-2019)

CS309329

2019-20 FluSurv-NET Influenza Hospitalization
Surveillance Project Case Report Form

Case ID:

1

9

2

0

E. Admission and Patient History (continued)
10g. Neurologic Disorder
Cerebral palsy
Cognitive dysfunction
Dementia/Alzheimer’s disease
Developmental delay
Down syndrome/Trisomy 21
Edwards syndrome/Trisomy 18
Epilepsy/Seizure/Seizure disorder
Neuropathy
Neural tube defects/spina bifida (see list)
Plegias/Paralysis/Quadriplegia
Traumatic brain injury (TBI), history of
Other, specify

Yes

No/Unknown

Yes

No/Unknown

10m. Pregnant
If pregnant,
Total # of pregnancies to date:

Yes

No/Unknown

Unknown

Total # of pregnancies to date that
resulted in a live birth:

Unknown

Specify total # of fetuses for current pregnancy
1
2
3
>3
Unknown
Yes

No/Unknown

Yes

No/Unknown

AIDS or CD4 count<200
Complement deficiency (See list)
Graft vs. host disease (GVHD)
HIV infection
Immunoglobulin deficiency/ immunodeficiency (See list)
Immunosuppressive therapy (within the 12 months prior to admission
(See instructions)
If yes, For what condition?:
Leukemia*
Lymphoma/Hodgkins/Non-Hodgkins (NHL)*
Metastatic cancer*
Multiple myeloma*
Solid organ malignancy*
If yes, which organ? _______________
Steroid therapy (within 2 weeks of admission)
Transplant, hematopoietic stem cell (Bone marrow transplant (BMT),
peripheral stem cell transplant (PSCT)), history of
Transplant, solid organ (SOT), history of
Other, specify:
*Current/in treatment or diagnosed in last 12 months
10j. Renal Disease
Yes
No/Unknown
Chronic kidney disease (CKD)/chronic renal insufficiency (CRI)
End stage renal disease (ESRD)
Dialysis (HD)
Glomerulonephritis (GN)
Nephrotic syndrome
Polycystic kidney disease (PCKD)
Other, specify:
10k. Gastrointestinal/Liver Disease
Yes
No/Unknown
(Do Not Record GERD)
Alcoholic hepatitis
Autoimmune hepatitis
Barrett’s esophagitis
Chronic liver disease
Chronic pancreatitis
Cirrhosis/End stage liver disease (ESLD)
Crohn’s disease
Esophageal varices
Esophageal strictures
Hepatitis B, chronic (HBV)
Hepatitis C, chronic (HCV)
Non-alcoholic fatty liver disease/NASH/NAFLD
Ulcerative colitis (UC)
Other, specify

Page 3 of 5

10l. Any obesity
Obese
Morbidly obese (ADULTS ONLY)

Specify, gestational age in weeks:

Unknown

If gestational age in weeks unknown, specify trimester of pregnancy:
1st (0 to 13 6/7 weeks

3rd (28 0/7 to end)

Unknown

No/Unknown
No/Unknown

Conditions(Do not record Osteoarthritis/OA)
Ankylosing spondylitis
Dermatomyositis
Juvenile idiopathic arthritis
Kawasaki disease
Microscopic polyangiitis
Polyarteritis nodosum (PAN)
Polymyalgia rheumatica
Polymyositis
Psoriatic arthritis
Rheumatoid arthritis (RA)
Systemic lupus erythematosus/SLE/Lupus
Systemic sclerosis
Takayasu arteritis
Temporal/Giant cell arteritis
Vasculitis, other (see list)
Other, specify
10p. Other
Feeding tube dependent (PEG, see list)
Trach dependent/Vent dependent
Wheelchair dependent
Other, specify

Yes

No/Unknown

10q. PEDIATRIC CASES ONLY
Abnormality of Airway (see instructions)
Yes
Chronic Lung Disease of Prematurity/
Bronchopulmonary dysplasia (BPD)
Yes
History of Febrile Seizures
Yes
Long term Aspirin Therapy
Yes
Premature
Yes
(gestation age <37weeks at birth for patients <2 yrs)
If yes, specify gestational age at birth in weeks:
Unknown gestational age at birth

2019-20 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form (CDC Rev. 07-2019)

No/Unknown
No/Unknown
No/Unknown
No/Unknown
No/Unknown

CS309329

2019-20 FluSurv-NET Influenza Hospitalization
Surveillance Project Case Report Form

1

Case ID:

9

2

0

F. Intensive Care Unit and Interventions
1. Was the patient admitted to an intensive care unit (ICU)?

/

1a. Date of first ICU Admission:

No

Unknown

/

/

1b. Date of first ICU Discharge:

Yes

2. Did patient receive invasive mechanical ventilation?
Yes

Unknown

/

Unknown

No

Unknown

3. Did patient receive extracorporeal membrane oxygenation
(ECMO or ‘on bypass’)?
Yes

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:

3c. Site where pathogen identified:
Blood
Bronchoalveolar lavage (BAL)
Pleural fluid
Other, specify:

Aspergillus (fungus)

/

3b. Date of culture:

/

3d. If Staphylococcus aureus, specify:

Methicillin resistant (MRSA)

Methicillin sensitive (MSSA)

4a. If yes, specify Pathogen 2:

Sensitivity unknown

4c. Site where pathogen identified:
Blood
Bronchoalveolar lavage (BAL)
Pleural fluid
Other, specify:

Aspergillus (fungus)

/

4b. Date of culture:

Cerebrospinal fluid (CSF)
Sputum
Endotracheal aspirate

/

4d. If Staphylococcus aureus, specify:

Methicillin resistant (MRSA)

Methicillin sensitive (MSSA)

Cerebrospinal fluid (CSF)
Sputum
Endotracheal aspirate

Sensitivity unknown

H. Viral Pathogens
Yes
1. Was patient tested for any viral respiratory pathogens within 14 days prior to or within 3 days after admission?
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:

No

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:

3a. Treatment 2:

4a. Treatment 3:

Yes

No

Unknown

Oseltamivir (Tamiflu)
Peramivir (Rapivab)
Zanamivir (Relenza)
Baloxavir marboxil (Xofluza)
Other, specify:
Unknown

2b. Start Date:

/

/

Start Date Unknown

2c. End Date:

/

/

End Date Unknown OR Total Duration (days):

Oseltamivir (Tamiflu)
Peramivir (Rapivab)
Zanamivir (Relenza)
Baloxavir marboxil (Xofluza)
Other, specify:
Unknown

3b. Start Date:

/

/

Start Date Unknown

3c. End Date:

/

/

End Date Unknown OR Total Duration (days):

Oseltamivir (Tamiflu)
Peramivir (Rapivab)
Zanamivir (Relenza)
Baloxavir marboxil (Xofluza)
Other, specify:
Unknown

4b. Start Date:

/

/

Start Date Unknown

4c. End Date:

/

/

End Date Unknown OR Total Duration (days):

5. Additional Treatment Comments:

Page 4 of 5

2019-20 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form (CDC Rev. 07-2019)

CS309329

2019-20 FluSurv-NET Influenza Hospitalization
Surveillance Project Case Report Form

1

Case ID:

9

2

0

J. Chest Radiograph – Based on radiology report only
1. Was a chest x-ray taken within 3 days of admission?

Yes

No

Unknown

2. Were any of these chest x-rays abnormal? 2b. For first abnormal chest x-ray, please check all that apply:
Report not available
Consolidation
Yes
No
Unknown
Air space density
Cavitation
2a. Date of first abnormal chest x-ray:
Air space opacity
ARDS (acute respiratory distress syndrome)
Bronchopneumonia/pneumonia
Lung infiltrate
/
/
Cannot rule out pneumonia
Interstitial infiltrate
K. Discharge Summary
No discharge summary available

1. Did the patient have any of the following new diagnoses at discharge? (check all that apply)
Acute encephalopathy/encephalitis
Acute Myocardial Infarction
Acute Myocarditis
Acute Renal Failure/Acute Kidney Injury
Acute respiratory distress syndrome (ARDS)
Acute respiratory failure
Asthma exacerbation

Yes
Yes
Yes
Yes
Yes
Yes
Yes

No/Unk
No/Unk
No/Unk
No/Unk
No/Unk
No/Unk
No/Unk

Bacteremia
Bronchiolitis
Congestive Heart Failure
COPD exacerbation
Diabetic Ketoacidosis
Guillan-Barre syndrome
Hemophagocytic syndrome

Other
Pleural Effusion/Empyema

Yes
Yes
Yes
Yes
Yes
Yes
Yes

No/Unk
No/Unk
No/Unk
No/Unk
No/Unk
No/Unk
No/Unk

Invasive pulmonary aspergillosis
Reyes syndrome
Rhabdomyolysis
Pneumonia
Sepsis
Seizures
Stroke (CVA)

Yes
Yes
Yes
Yes
Yes
Yes
Yes

No/Unk
No/Unk
No/Unk
No/Unk
No/Unk
No/Unk
No/Unk

2. What was the outcome
of the patient?

2a. If discharged alive, please indicate to where:
Private residence
Rehabilitation Facility
Group home/Retirement home
Home with services
Corrections Facility
Psychiatric Facility
Alive
Homeless/Shelter
Deceased
Hospice
Unknown
Unknown
Nursing home /Skilled Nursing Facility
Assisted living/Residential care
Other long term care facility
Alcohol/Drug Abuse Treatment
Other, specify:
LTACH
3. If patient was pregnant on admission, indicate pregnancy status at discharge:
Still pregnant
No longer pregnant
Unknown
3a. If patient was pregnant on admission but no longer pregnant at discharge, indicate pregnancy outcome at discharge:
Miscarriage (intrauterine death at <22 weeks GA)
Stillbirth (intrauterine death at ≥22 weeks GA)
Ill newborn

Newborn died

Healthy newborn

Abortion

Unknown

/

3b. If no longer pregnant, indicate date of delivery or end of pregnancy:

/

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:
4. Interview:

Injected Vaccine
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

/

Yes, specific date unknown

/

No

Yes, specific date unknown

/

No

Yes, specific date unknown

No

6a. If yes, specify 2nd dosage date information:

/

/

Unknown

Date Unknown
Combination of both

5. If patient < 9 yrs, did patient receive any seasonal influenza vaccine in previous seasons?
Yes

Unknown

Date Unknown
Combination of both

Nasal Spray/FluMist

6. If patient < 9 yrs, did patient receive 2nd influenza vaccine in current season?

Unknown

Date Unknown
Combination of both

Nasal Spray/FluMist

Nasal Spray/FluMist

Unknown

Date Unknown
Combination of both

Nasal Spray/FluMist

/

Injected Vaccine

No

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:

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2019-20 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form (CDC Rev. 07-2019)

CS309329