Influenza Hospitalization Surveillance Network Case Repo

U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
ATLANTA, GA 30329

2020-21 FluSurv-NET Influenza Hospitalization
Surveillance Project Case Report Form
2 0

FluSurv-NET Case ID:

2

1

FORM APPROVED
OMB NO. 0920-0978

RSV-NET Case ID:

COVID-NET Case ID:
A. Patient Data – THIS INFORMATION IS NOT SENT TO CDC

Last Name:

First Name:

Middle Name:

Address:

Chart Number:
Address Type:

City:

State:

Phone No. 2:

Zip Code:

Phone No.1:

Emergency Contact:

Emergency Contact Phone:

PCP Clinic Name 1:

PCP Phone 1:

PCP Fax 1:

PCP Clinic Name 2:

PCP Phone 2:

PCP Fax 2:

Site Use 1:

Site Use 2:

Site Use 3:

No PCP

CDCTrack:

B. Abstractor Information – THIS INFORMATION IS NOT SENT TO CDC
1. Abstractor Name:

/

2. Date of Abstraction:

/

C. Enrollment Information
1. Case Classification:

2. Admission Type:

Prospective Surveillance
Discharge Audit
9. Race:

5. Case Type:

11. Type of Insurance (select all that apply):

Hispanic or Latino
Non-Hispanic/Latino
Not Specified

Private
Medicare
Medicaid/state assistance program
Military
Indian Health Service
Incarcerated
Uninsured
Unknown
Other, specify:

6. Date of Birth:

7. Age:

/

Unknown

/

Male
Female

12. Was patient discharged from any hospital within 1 week prior to
the current admission date?
Yes

No

Unknown

13. Hospital ID Where Patient Treated:
13a. Admission Date:

/

/

13b. Discharge Date:

/

/

14c. Transfer Date:

15. Where did the patient reside at the time of hospitalization? (Indicate TYPE of residence.)
Private residence
Alcohol/Drug Abuse Treatment
Private residence with services
Hospitalized at birth
Homeless/shelter
Rehabilitation facility
Nursing home/Skilled nursing facility
Corrections facility

8. Sex:

Years
Months (if < 1 yr)
Days (if < 1 month)

14b. Transfer Hospital Admission Date:

14a. Transfer Hospital ID:

14. Was patient transferred from another hospital?
No

4. County:

Pediatric
Adult

10. Ethnicity

White
Black or African American
Asian/Pacific Islander
American Indian or
Alaska Native
Multiracial
Not specified

Yes

3. State:

Hospitalization
Observation only

/

/

/

/

Hospice
Assisted living/Residential care
LTACH
Group/Retirement home

Psychiatric facility
Other long term care facility
Other, specify:
Unknown

15a. If resident of a facility, indicate NAME of facility:
D. Influenza Testing Results (can add up to 4 test results in database)
1. Test 1:
1a. Result:

Rapid Antigen

Molecular Assay

Flu A (no subtype)
2009 H1N1
H1, Unspecified

1b. Specimen collection date:
2. Test 2:
2a. Result:

Rapid Antigen

/

Flu A (no subtype)
2009 H1N1
H1, Unspecified

3a. Result:

Rapid Antigen

H1, Seasonal
H1
H3
/

/

Molecular Assay

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

H1, Seasonal
H1
H3
/

/

Rapid Molecular Assay
Flu A, Unsubtypable
Flu B (no lineage)
Flu B, Victoria

Viral Culture

Serology

Flu B, Yamagata
Flu A & B
Flu A/B (not distiguished)

1c. Specimen ID:
Rapid Molecular Assay
Flu A, Unsubtypable
Flu B (no lineage)
Flu B, Victoria

Flu A, Unsubtypable
Flu B (no lineage)
Flu B, Victoria

Unknown Type
Negative
H3N2v

Method Unknown
Other, please specify:

1d. Testing facility ID:
Viral Culture

Serology

Flu B, Yamagata
Flu A & B
Flu A/B (not distiguished)

2c. Specimen ID:
Rapid Molecular Assay

Fluorescent Antibody

Fluorescent Antibody
Unknown Type
Negative
H3N2v

Method Unknown
Other, please specify:

2d. Testing facility ID:
Viral Culture

Serology

Flu B, Yamagata
Flu A & B
Flu A/B (not distiguished)

3c. Specimen ID:

Fluorescent Antibody
Unknown Type
Negative
H3N2v

Method Unknown
Other, please specify:

3d. Testing facility 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).
08/06/2020

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Case ID:

1
E. ICU and Other Interventions

1. Was the patient admitted to an intensive care unit (ICU)?
1a. Date of 1st ICU Admission:
2. BiPAP or CPAP use?

Yes

/

5. ECMO?

Yes

No

No

/

No

4. Invasive mechanical ventilation?

Yes

Unknown

No

/

/
Yes

No

Unknown
Unknown

Unknown

6. Vasopressor use?

Unknown

1b. Date of 1st ICU Discharge:

3. High flow nasal cannula (e.g., Vapotherm)?

Unknown

Yes

Unknown

Yes

No

Unknown

(Common vasopressors are Dobutamine, Dopamine, Epinephrine, Milrinone, Neosynephrine, Norepinephrine, Vasopressin)
Yes

7. Renal Replacement Therapy (RRT) or Dialysis?

No

Unknown

Includes Peritoneal Dialysis (PD), Hemodialysis (HD), Continuous
Venovenous Hemofiltration (CVVH), Continuous Venovenous Hemodialysis
(CVVHD), and Slow Continuous Ultrafiltration (SCUF)

F. Outcome
1. What was the outcome of the patient upon discharge?

Alive

Died during hospitalization

Unknown

2. If patient discharged alive, please indicate to where:
Private residence
Private residence with services
Homeless/Shelter
Nursing home/Skilled nursing facility

Alcohol/Drug Abuse Treatment
Rehabilitation facility
Corrections facility
Hospice

Assisted living/Residential care
LTACH
Group/Retirement home
Psychiatric facility

Other long term care facility
Against medical advice (AMA)
Discharged to another hospital
Other, specify:
Unknown

3. Additional notes regarding discharge:

G. Admission and Patient History
1. Acute signs/symptoms present at admission (began or worsened within 2 weeks prior to admission) (Select all that apply):

None of the below signs/symptoms

Non-respiratory symptoms
Altered mental status/confusion

Fever/chills

Seizures

Respiratory symptoms
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 influenza test):
Inch
Cm
Unknown

3. Height
6. Smoker (tobacco):

08/06/2020

Current

4. Weight
Former

Lbs
Kg
Unknown

URI/ILI
Wheezing
/

/

Unknown

5. BMI (non-pregnant cases and cases ≥ 2 years only)

Not applicable
Unknown

No/Unknown

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H. Underlying Medical Conditions

1. Did the patient have any of the following pre-existing medical conditions? (Select all that apply):
1a. Asthma/Reactive Airway Disease:
1b. Chronic Lung Disease:

Yes

Yes

Yes

No

Unknown

1e. Cardiovascular Disease, continued:

No/Unknown

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 regurgitation (MR)
Mitral stenosis (MS)
Peripheral artery disease (PAD)
Peripheral vascular disease (PVD)
Pulmonary embolism (PE), history of
Pulmonary hypertension (PHTN)
Pulmonic regurgitation
Pulmonic stenosis
Transient ischemic attack (TIA), history of
Tricuspid regurgitation (TR)
Tricuspid stenosis
Ventricular fibrillation (VF, VFib), history of
Ventricular tachycardia (VT, VTach), history of
Other, specifiy:

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)
Obstructive sleep apnea (OSA)
Oxygen (O2) dependent
Pulmonary fibrosis
Restrictive lung disease
Sarcoidosis
Other, specifiy:

1c. Chronic Metabolic Disease:
Yes
No/Unknown
Adrenal Disorders (Addison’s disease, 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
1f. Neurologic Disorder:
Yes
No/Unknown
Parathyroid dysfunction (hyperparathyroidism, hypoparathyroidism)
Amyotrophic lateral sclerosis (ALS)
Thyroid dysfunction (Grave’s disease, Hashimoto’s disease, hyperthyroidism, hypothyroidism)
Cerebral palsy
Other, specifiy:
Cognitive dysfunction
Dementia/Alzheimer’s disease
1d. Blood Disorders/Hemoglobinopathy:
Yes
No/Unknown
Developmental delay
Alpha thalassemia
Down syndrome/Trisomy 21
Aplastic anemia
Edward’s syndrome/Trisomy 18
Beta thalassemia
Epilepsy/seizure/seizure disorder
Coagulopathy (Factor V Leiden, Von Willebrand disease (VWD), see list)
Mitochondrial disorder (See list)
Hemoglobin S-beta thalassemia
Multiple sclerosis (MS)
Leukopenia
Muscular dystrophy (See list)
Myelodysplastic syndrome (MDS)
Myasthenia gravis (MG)
Neutropenia
Neural tube defects/Spina bifida (See list)
Pancytopenia
Neuropathy
Polycythemia vera
Parkinson’s disease
Sickle cell disease
Plegias/Paralysis/Quadriplegia
Splenectomy/Asplenia
Scoliosis/Kyphoscoliosis
Thrombocytopenia
Traumatic brain injury (TBI), history of
Other, specifiy:
Other, specifiy:
1e. Cardiovascular Disease:
Yes
No/Unknown
1g. History of Guillain-Barre Syndrome:
Yes
No/Unknown
Aortic aneurysm (AAA), history of
1h. Immunocompromised Condition:
Yes
No/Unknown
Aortic/Mitral/Tricuspid/Pulmonic valve replacement, history of
Aortic regurgitation (AR)
AIDS or CD4 count<200
Aortic stenosis (AS)
Complement deficiency (See list)
Atherosclerotic cardiovascular disease (ASCVD)
Graft vs. host disease (GVHD)
Atrial fibrillation (AFib)
HIV infection
Atrioventricular (AV) blocks
Immunoglobulin deficiency/immunodeficiency (See list)
Automated implantable devices (AID/AICD)/Pacemaker
Immunosuppressive therapy
(within the 12 months previous to admission) (see instructions):
Bundle branch block (BBB/RBBB/LBBB)
If yes, for what condition?
Cardiomyopathy

Carotid stenosis

Cerebral vascular accident (CVA)/Incident/Stroke, history of
Leukemia*
Lymphoma/Hodgkins/Non-Hodgkins (NHL)*
Metastatic cancer*
Multiple myeloma*
Solid organ malignancy*
If yes, which organ?
Steroid therapy (within 2 weeks of admission) (see instructions)
Transplant, hematopoietic stem cell (bone marrow transplant (BMT),
peripheral stem cell transplant (PSCT)), history of
Transplant, solid organ (SOT), history of
Other, specifiy:
*Current/in treatment or diagnosed in last 12 months
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H. Underlying Medical Conditions (continued)

1i. Any Obesity?

Yes

1n. Rheumatologic/Autoimmune/Inflammatory
Conditions (Do Not Record OA):

No/Unknown

Obese

Yes

No/Unknown

1k. Post-Partum (two weeks or less)
1l. Renal Disease

Yes

Yes

No/Unknown

No/Unknown

Chronic kidney disease (CKD)/chronic renal insufficiency (CRI)
Dialysis (HD)
End stage renal disease (ESRD)
Glomerulonephritis (GN)
Nephrotic syndrome
Polycystic kidney disease (PCKD)
Other, specifiy:

1m. Gastrointestinal/Liver Disease (Do Not Record GERD):

Yes

No/Unknown

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, specifiy:

Morbidly obese (ADULTS ONLY)

1j. Pregnant?

Yes

No/Unknown

1o. Hypertension:

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 (NAFLD)/NASH
Ulcerative colitis (UC)
Other, specifiy:

1p. Other:

Yes
Yes

No/Unknown
No/Unknown

Feeding tube dependent (PEG, see list)
Trach dependent/Vent dependent
Wheelchair dependent
Other, specify

1q. PEDIATRIC CASES ONLY
Abnormality of airway (see instructions)
Chronic lung disease of prematurity/Bronchopulmonary dysplasia (BPD)
History of febrile seizures
Long term aspirin therapy
Premature (gestation age <37 weeks at birth for patients < 2 years)
If yes, specify gestational age at birth in weeks:
Unknown gestational age at birth

I. Viral Pathogens
1. Was patient tested for any of the following viral respiratory pathogens within 14 days prior to or within 7 days after
admission, and if deceased, 14 days prior to death or 24 hours after death?

Yes

No

Unknown

1a. Respiratory syncytial virus/RSV

Yes, positive

Yes, negative

Not tested/Unknown

Date:

/

/

1b. Coronavirus SARS-CoV-2

Yes, positive

Yes, negative

Not tested/Unknown

Date:

/

/

J. Influenza Treatment (can add up to 4 treatment courses in database)
1. Did the patient receive treatment for influenza?
1a. T reatment 1:

Yes

Baloxavir marboxil (Xofluza)
Oseltamivir (Tamiflu)

1b. Start date:

/

2a. T reatment 2:

Baloxavir marboxil (Xofluza)
Oseltamivir (Tamiflu)

2b. Start date:

08/06/2020

/

/

/

Unknown

Unknown

No

Unknown
Peramivir (Rapivab)
Zanamivir (Relenza)
1c. End date:

/

Other, specify:
Unknown

/

Peramivir (Rapivab)
Zanamivir (Relenza)
2c. End date:

Page 4 of 5

/

Unknown
Other, specify:
Unknown

/

Unknown

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K. Discharge Summary

1. Did the patient have any of the following new diagnoses at discharge? (select all that apply)
Acute encephalopathy/encephalitis
Acute liver failure
Acute myocardial infarction
Acute myocarditis
Acute renal failure/acute kidney injury
Acute respiratory distress syndrome (ARDS)
Acute respiratory failure
Asthma exacerbation
Bacteremia
Bronchiolitis
Bronchitis
Chronic lung disease of prematurity/BPD
Congestive heart failure
COPD exacerbation
Deep vein thrombosis (DVT)
Diabetic ketoacidosis

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
     Yes
  Yes
           Yes

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

No discharge summary available
Disseminated intravascular coagulation (DIC)
Yes
No/Unknown
Guillain-Barre syndrome
Yes
No/Unknown
Hemophagocytic syndrome
Yes
No/Unknown
Invasive pulmonary aspergillosis
Yes
No/Unknown
Kawasaki disease
Yes
No/Unknown
Multisystem inflammatory syndrome in
children (MIS-C)
Yes
No/Unknown
Other thrombosis/embolism/coagulopathy
Yes
No/Unknown
Pneumonia
Yes
No/Unknown
Pulmonary embolism (PE)

Yes
No/Unknown
Reyes Syndrome
Yes
No/Unknown
Rhabdomyolysis
Yes
No/Unknown
Sepsis
Yes
No/Unknown
Seizures
Yes
No/Unknown
Stroke (CVA)
Yes
No/Unknown
Toxic shock syndrome (TSS)
Yes
No/Unknown

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:

3. Primary Care Provider /LTCF:

Yes, full date known

4. Interview:

Yes, full date known

Proxy

4a. If yes, specify dosage date information:
4b. If patient < 9 yrs, specify vaccine type:

Combination of both
No

Unknown

Nasal Spray/FluMist
Yes, specific date unknown

Unsuccessful Attempt

Unknown type
Unsuccessful Attempt

No

Unknown

Not Checked

Unknown type
Unsuccessful Attempt

Date Unknown

Yes, specific date unknown
/

Combination of both
No

Unknown

Not Checked

Unknown type
Unsuccessful Attempt

Date Unknown

Injected Vaccine

Nasal Spray/FluMist

Combination of both

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

Yes

No

Unknown

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

Yes

No

Unknown

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

Date Unknown

/

Not Checked

Combination of both

Nasal Spray/FluMist

/

Not Checked

Date Unknown

/

Injected Vaccine

Patient

Yes, specific date unknown

/

3b. If patient < 9 yrs, specify vaccine type:

Unknown

Date Unknown

/

Injected Vaccine

No

Nasal Spray/FluMist

/

2b. If patient < 9 yrs, specify vaccine type:

3a. If yes, specify dosage date information:

Yes, specific date unknown

/

Unknown type

N. Additional Comments

08/06/2020

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