CryptoNet Case Report Form

Form Approved
OMB Control No.: 0920--21DI
Expiration date: XX/XX/XXXX

CryptoNet Case Report Form
All fields to be completed by state and local health department partners.
Please contact CryptoNet staff at [email protected] with any questions.

I. Case Report ID & Investigator Information
State Case Laboratory ID
State Case Epidemiology ID
NNDSS Case ID
NORS ID
Outbreak status: ☐ Sporadic (not outbreak-associated) case

☐ Outbreak-associated case ☐Unknown

II. Case-Patient’s Demographics
Residence:

County:

State:

(choose one) ☐Years ☐Months ☐Days

Age:

Sex: ☐ Female ☐Male ☐ Unknown

Interviewer instructions: Only Hispanic/Latino and Not Hispanic/Latino should be given as options to the respondent.
Unknown may be selected if indicated by the respondent.
Ethnicity: ☐Hispanic/Latino
☐ Not Hispanic/Latino
☐Unknown
Interviewer instructions: Other Race and Unknown should not be given as options to the respondent. Other Race and
Unknown may be selected if indicated by the respondent.
Race (check all that apply): ☐ American Indian/Alaska Native ☐Asian ☐ Black/African American
☐Native Hawaiian/Other Pacific Islander

☐White

☐ Other Race (specify)

☐Unknown

III. Laboratory Information
Did the specimen(s) have a positive or negative test result? ☐ Positive
☐ Negative
Please specify what test type was completed (per specimen):
Test used
AcidDFA
EIA
GI/Enteric
Rapid IC
fast
Panel
Specimen 1

☐ Unknown
PCR

Other,
specify

Specimen 2
Specimen 3

Public reporting burden of this collection of information is estimated to average 15 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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia
30333; ATTN: PRA 0920-21DI

IV. Symptom Onset & Exposure History
Symptom onset date:
Patient deceased:

☐ Yes

☐ No

☐ Unknown

In 14 days before symptom onset, did the case-patient:
Yes
Travel (outside of the area where he/she lives or works/goes to
school):
Internationally?
Domestically?
If Yes for either, please specify:
Swim in, play in, wade in, or enter a/an:
Ocean?
Natural hot spring?
Lake, pond, river, or stream?
Swimming pool or kiddie/wading pool?
If Swimming pool, please specify type:
Water playground, interactive fountain, splash pad, or spray park?
Hot tub, spa, whirlpool, or Jacuzzi?
Other recreational water source?
Other, specify:
Consume water from:
Municipal/public supply (i.e., does case-patient receive water bill
from public or private utility)?
Private well (e.g., used by 1 household)?
Common well (e.g., used by >1 household)?
Commercially Bottled water?
Spring, lake, creek, river, stream, or cistern (i.e., untreated
surface water)?
Other drinking water source?
Other, specify
Consume raw/unpasteurized milk or dairy products?
Consume raw/unpasteurized fruit or vegetable juice or cider?
Attend any large gatherings (e.g., wedding, party/picnic,
festival/fair, or sports event)?
Have contact with children in a childcare setting?
Have contact with diapered children or adult(s)?
Visit, work, or live on farm, ranch, petting zoo, or other setting
that has farm animals?

No

Unknown

Have contact with animal manure, pet feces, or compost?
Have contact with a:

Yes

No

Unknown

Yes

No

Unknown

Cow?
Calf (baby cow)?
Sheep?
Lamb (baby sheep)?
Goat?
Kid (baby goat)?
Horse?
Foal (baby horse)?
Cat?
Kitten?
Dog?
Puppy?
Squirrel?
(Deer) mouse?
Raccoon?
Chipmunk?
Chicken?
Chick (baby chicken)?
Turkey?
Poult (baby turkey)?
Other animal?
Other, specify:
Have sexual contact with a:
Male?
Female?