CryptoNet Case Report Form

F orm 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.

1. Case Report ID & Investigator Information

Please contact CryptoNet staff at [email protected] with any questions.

State Case Laboratory ID
State Case Epidemiology ID
NNDSS Case ID
NORS ID

II. Case-Patient’s Demographics

Outbreak status: ☐ Sporadic (not outbreak-associated) case ☐ Outbreak-associated case ☐Unknown

Residence: County: State:

Age: (choose one) ☐Years ☐Months ☐Days 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 ☐ Unknown

Please specify what test type was completed (per specimen):

Test used	Acid-fast	DFA	EIA	GI/Enteric Panel	Rapid IC	PCR	Other, specify
Specimen 1
Specimen 2
Specimen 3

Symptom onset date:

Patient deceased: ☐ Yes ☐ No ☐ Unknown

IV. Symptom Onset & Exposure History

In 14 days before symptom onset, did the case-patient:

	Yes	No	Unknown
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?
Have contact with animal manure, pet feces, or compost?
Have contact with a:	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:	Yes	No	Unknown
Male?
Female?

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

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Perez, Ariana (CDC/DDID/NCEZID/DFWED)
File Modified	0000-00-00
File Created	2021-08-03