0920-1011 Avian Influenza Initial Case Investigation Form (English

Avian Influenza Initial Case Investigation Form

For health departments to collect data on cases under investigation (CUI) for human infection with avian influenza viruses in the United States. Please black-out or retain information in the shaded boxes; do not send to CDC.

Reporting county:			Case residence county:					Case phone:
Interviewer name:			Phone:					Email:
Case name:			Parent/guardian name (for minors):
Please send the portion below to the Influenza Division at CDC (email: [email protected])
1.Date of report: (mm/dd/yyyy):______________							2.Person reporting: __________________ 3.Contact phone: ____________________
4.State Case ID #:					5.Specimen Collection Date (mm/dd/yyyy): _________________
6.What is the subtype? (Required) ☐Influenza A(H1N1) variant ☐Influenza A(H1N2) variant ☐Influenza A(H3N2) variant ☐Influenza A(H5N1)	☐Influenza A(H7N9) ☐Unknown ☐Other: _______________­				7.State Lab Specimen ID #:
					8.Test type performed on specimen: ☐RT-PCR ☐Rapid antigen (not recommended) ☐Other: ____________
					9.Was the specimen submitted to CDC? ☐Yes ☐No ☐Unknown
10.At the time of this report, is the case ☐Confirmed ☐Probable ☐Under Investigation ☐Not a Case
11.State of Residence:		12.Country of usual residence:				13.If usual resident of U.S., county of residence:
14.Date of Birth (mm/dd/yyyy):					15.Sex: ☐Male ☐Female ☐Other
16a.Age: ______ 16b.Age Type: ☐Days ☐Weeks ☐Months ☐Years
17.Did the patient have any of the following symptoms: (select all that apply) ☐Fever (≥100°F) ☐Chills ☐Cough ☐Fatigue ☐Sore Throat ☐Runny or stuffy nose ☐Sneezing ☐Nausea/vomiting ☐Diarrhea ☐Headache ☐Rash ☐Muscle/body aches ☐Red/draining eyes ☐Difficulty breathing/shortness of breath ☐ Seizures ☐Other: ____________
18a.Illness Onset Date (mm/dd/yyyy): ____________ 18b.Illness Resolution Date (mm/dd/yyyy): ____________					19a. Hospitalization? ☐Yes ☐No ☐Unknown 19b. If yes, date of hospitalization (mm/dd/yyyy):____________
20a.ICU? ☐Yes ☐No ☐Unknown 20b.If yes, date of ICU admission (mm/dd/yyyy): _________					21a.Death? ☐Yes ☐No ☐Unknown 21b.If yes, date of death (mm/dd/yyyy): ____________
22a.Has this person taken influenza antiviral chemoprophylaxis? ☐Yes ☐No ☐Unknown 22b.If yes, date started: (mm/dd/yyyy) _____/_____/______					23a.Has this person begun influenza antiviral treatment? ☐Yes ☐No ☐Unknown 23b.If yes, date started: (mm/dd/yyyy) _____/_____/______
24.Contact of a confirmed case? ☐Yes ☐No ☐Unknown					25.Employed at a health care facility? ☐Yes ☐No ☐Unknown
26.Any wild bird/poultry contact in 10 days before illness onset or positive test date if no symptoms?☐Yes☐No ☐Unknown
27a.If wild bird/poultry contact, where did this contact occur? (select all that apply) ☐Participated in a depopulation event ☐Hunted and harvested a wild bird ☐Worked or lived on farm where HPAI was detected ☐Other, specify: ___________________________________ 27b.If participated in a depopulation event or worked/lived on a farm where HPAI was detected, indicate outbreak ID:_____
28.What activities did the person engage in during wild/bird poultry contact? (select all that apply) ☐Lived in vicinity of birds……………..If yes, duration* ______ ☐Direct handling of birds……………..If yes, duration ______ ☐Walking/working in area with birds..If yes, duration ______ ☐Cleaning environment/manure…….If yes, duration ______ ☐Dressing of game birds…………….If yes, duration ______ ☐Other, specify: __________............If yes, duration ______ *Duration activity performed in HH:MM.					29.While performing these activities, what PPE was used/preventive measures taken? (select all that apply) ☐Wore gloves……………………If yes, entire duration? ☐Yes ☐No ☐Wore eye protection…………..If yes, entire duration? ☐Yes ☐No ☐Wore medical facemask……...If yes, entire duration? ☐Yes ☐No ☐Wore N95/respirator…………..If yes, entire duration? ☐Yes ☐No ☐Wore gown…………………….If yes, entire duration? ☐Yes ☐No ☐Washed hands afterward…….If yes, entire duration? ☐Yes ☐No ☐Changed clothes afterward…..If yes, entire duration? ☐Yes ☐No
30.Any swine contact in 7 days before illness onset or positive test date if no symptoms? ☐Yes ☐No ☐Unknown				31a.Agricultural event/live animal market attendance in 7 days prior to illness onset or positive test date if no symptoms? ☐Yes ☐No ☐Unknown 31b.If yes, specify name and date (mm/dd/yyyy): ______________________
32.Has the person traveled outside of the U.S. in the 10 days prior to illness onset or positive test date if no symptoms? ☐Yes ☐No ☐Unknown If yes, list the city, country, and dates of travel (mm/dd/yyyy): ___________________________________________________
Notes/Comments:

• For CUIs, arrange for nasopharyngeal (NP) swab collection and RT-PCR testing at a state public health laboratory.

• Patients with influenza-like illness should discuss possible antiviral treatment with a healthcare provider.

• Healthcare facilities should use appropriate isolation precautions for cases under investigation for infection with novel influenza A viruses. Non-hospitalized cases under investigation should stay home from school, work, and social gatherings until fever is gone for at least 24 hours without the use of fever-reducing medications.

• If this case is later determined to be a confirmed case of infection with novel influenza A, please notify CDC and complete the CDC Human Infection with Novel Influenza A Virus Case Report Form.