Influenza Hospitalization Surveillance Network Case Repo

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

2021-22 FluSurv-NET Influenza Hospitalization
Surveillance Project Case Report Form
2 1

FluSurv-NET Case ID:

2

2

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:

Emergency Contact:

Phone No. 1:
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:

10. Ethnicity:

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

No

4. County:

5. Case Type:

Hispanic or Latino
Non-Hispanic/Latino
Not Specified

6. Date of Birth:

Pediatric
Adult
11. Type of Insurance (select all that apply):
Private
Medicare
Medicaid/state assistance program
Military
Indian Health Service
Incarcerated
Uninsured
Unknown
Other, specify:

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?
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

/

3a. Result:

Flu A (no subtype)
2009 H1N1
H1, Unspecified

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 distinguished)

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 distinguished)

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 distinguished)

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 25 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).
08/26/2021

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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

6. Vasopressor use?

Yes

No

Unknown

Unknown

Unknown

Yes

No

No

/

No

4. Invasive mechanical ventilation?

Yes

1b. Date of 1st ICU Discharge:

/

/

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

Yes

5. ECMO?

Unknown

Unknown

Yes

No

Unknown

No

Unknown

Unknown

(Common vasopressors are Dobutamine, Dopamine, Epinephrine, Milrinone, Neosynephrine, Norepinephrine, Vasopressin)
7. Renal Replacement Therapy (RRT) or Dialysis?

Yes

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. Reason for admission:
Influenza-related illness

Inpatient surgery procedures

Trauma

OB/Labor and delivery admission

Psychiatric admission needing    acute medical care

Other, specify:

Unknown

2. 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
Abdominal pain

Chest pain

Dysgeusia/decreased taste

Headache

Rash

Altered mental status/confusion

Conjunctivitis

Fatigue

Muscle aches/myalgias

Seizures

Anosmia/decreased smell

Diarrhea

Fever/chills

Nausea/vomiting

Respiratory symptoms
Congested/runny nose

For cases < 2 years
Apnea
Cyanosis

Cough

Shortness of breath/respiratory distress

URI/ILI

Hemoptysis/bloody sputum

Sore throat

Wheezing

Decreased vocalization/stridor

Hypothermia

Dehydration

Inability to eat/poor feeding

3. Date of onset of acute respiratory symptoms (within 2 weeks before a positive influenza test):
4. Height:

Inch
Cm
Unknown

5. Weight:

7. Smoker (tobacco):

Current

Former

No/Unknown

9. Substance Abuse:

Current

Former

No/Unknown

Lbs
Kg
Unknown

8. Alcohol abuse:

/

Lethargy

/

Unknown

6. BMI (non-pregnant cases and cases ≥ 2 years only):
Current

Former

Not applicable
Unknown

No/Unknown

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

Polysubstance abuse - not otherwise specified

Opioids

Other, specify:

11. Code status on admission:

08/26/2021

Cocaine

Methamphetamines

Marijuana

Unknown
Full code

DNR/DNI/CMO

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

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

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

1f. Neurologic Disorder:
Yes
No/Unknown
1c. Chronic Metabolic Disease:
Yes
No/Unknown
Amyotrophic lateral sclerosis (ALS)
Adrenal Disorders (Addison’s disease, adrenal insufficiency,
Cerebral palsy
Cushing syndrome, congenital adrenal hyperplasia)
Cognitive dysfunction
Diabetes mellitus (DM)
Dementia/Alzheimer’s disease
Glycogen or other storage diseases (See list)
Developmental delay
Hyper/Hypo- function of pituitary gland
Down syndrome/Trisomy 21
Inborn errors of metabolism (See list)
Edward’s syndrome/Trisomy 18
Metabolic syndrome
Epilepsy/seizure/seizure disorder
Parathyroid dysfunction (hyperparathyroidism, hypoparathyroidism)
Mitochondrial disorder (See list)
Thyroid dysfunction (Grave’s disease, Hashimoto’s disease, hyperthyroidism, hypothyroidism)
Multiple sclerosis (MS)
1d. Blood Disorders/Hemoglobinopathy:
Yes
No/Unknown
Muscular dystrophy (See list)
Myasthenia gravis (MG)
Alpha thalassemia
Neural tube defects/Spina bifida (See list)
Aplastic anemia
Neuropathy
Beta thalassemia
Parkinson’s disease
Coagulopathy (Factor V Leiden, Von Willebrand disease (VWD), see list)
Plegias/Paralysis/Quadriplegia
Hemoglobin S-beta thalassemia
Scoliosis/Kyphoscoliosis
Leukopenia
Traumatic brain injury (TBI), history of
Myelodysplastic syndrome (MDS)
Neutropenia
1g. History of Guillain-Barre Syndrome:
Yes
No/Unknown
Pancytopenia
Polycythemia vera
1h. Immunocompromised Condition:
Yes
No/Unknown
Sickle cell disease
AIDS or CD4 count<200
Splenectomy/Asplenia
Complement deficiency (See list)
Thrombocytopenia
Graft vs. host disease (GVHD)
HIV infection
1e. Cardiovascular Disease:
Yes
No/Unknown
Immunoglobulin deficiency/immunodeficiency (See list)
Aortic aneurysm (AAA), history of
Immunosuppressive therapy
Aortic/Mitral/Tricuspid/Pulmonic valve replacement, history of
(within the 12 months previous to admission) (see instructions):
Aortic regurgitation (AR)
If yes, for what condition?
Aortic stenosis (AS)

Atherosclerotic cardiovascular disease (ASCVD)

Atrial fibrillation (AFib)
Leukemia*
Atrioventricular (AV) blocks
Lymphoma/Hodgkins/Non-Hodgkins (NHL)*
Automated implantable devices (AID/AICD)/Pacemaker
Metastatic cancer*
Bundle branch block (BBB/RBBB/LBBB)
Multiple myeloma*
Cardiomyopathy
Solid organ malignancy*
Carotid stenosis
If yes, which organ?
Steroid therapy (within 2 weeks of admission) (see instructions)
Cerebral vascular accident (CVA)/Incident/Stroke, history of
Transplant, hematopoietic stem cell (bone marrow transplant (BMT),
Congenital heart disease (Specify)
peripheral stem cell transplant (PSCT)), history of
Atrial septal defect
Transplant, solid organ (SOT), history of
Pulmonic stenosis
*Current/in treatment or diagnosed in last 12 months
Tetralogy of Fallot
Ventricular septal defect
Other, specify:
Coronary artery bypass grafting (CABG), history of
Coronary artery disease (CAD)

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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

Severely/morbidly obese (ADULTS ONLY)

1j. Pregnant?

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)

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

Yes

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)

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)

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. Bacterial Pathogens - Sterile or respiratory site only (can record up to 5 pathogens in database)
1. Were any culture tests performed within 7 days of admission? (For patients that died in the hospital, include culture
tests performed either 1) within 7 days of admission, 2) within 3 days prior to death, or 3) within 24 hours after death)

Yes

No

Unknown

2. If yes, was there a positive culture for aspergillus, mucormycosis, or a bacterial pathogen?

Yes

No

Unknown

2a. If yes, specify Pathogen 1:

Aspergillus (fungus)

Mucormycosis (fungus)

2b. Date of culture:
/

2c. Site where pathogen identified:

2d. If Staphylococcus aureus, specify:
3a. If yes, specify Pathogen 2:

Blood
Sputum

Bronchoalveolar lavage (BAL)
Endotracheal aspirate

Methicillin resistant (MRSA)
Aspergillus (fungus)

Pleural fluid
Other, specify:

Cerebrospinal fluid (CSF)

Methicillin sensitive (MSSA)   Sensitivity unknown
Mucormycosis (fungus)

3b. Date of culture:
/

3c. Site where pathogen identified:

3d. If Staphylococcus aureus, specify:

08/26/2021

Blood
Sputum

Bronchoalveolar lavage (BAL)
Endotracheal aspirate

Methicillin resistant (MRSA)

/

Pleural fluid
Other, specify:

/

Cerebrospinal fluid (CSF)

Methicillin sensitive (MSSA)    Sensitivity unknown

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J. Viral Pathogens

1. Was patient tested for any of the viral respiratory pathogens within 14 days prior to or within 7 days of admission?
(For patients that died in the hospital, include tests performed either 1) within 14 days prior to or within 7 days of admission,
2) within 14 days prior to death, or 3) within 24 hours after death)

Yes

No

Unknown

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 SARS-CoV-2

Yes, positive

Yes, negative

Not tested/Unknown

Date:

/

/

Not tested/Unknown

Date:

/

/

1j. Coronavirus, other:

Yes, positive

Yes, negative

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

Yes

No

Baloxavir marboxil (Xofluza)
Oseltamivir (Tamiflu)

1b. Start date:

/

/

2. Did the patient receive treatment for influenza?
2a. T reatment 2:

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

Unknown
Yes

No

Baloxavir marboxil (Xofluza)
Oseltamivir (Tamiflu)

2b. Start date:

/

/

Unknown
Other, specify:
Unknown

/

/

Unknown

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

Unknown

Other, specify:
Unknown

/

/

Unknown

L. Chest Imaging – Based on radiology report only
1. Was a chest x-ray taken within 3 days of hospitalization?
Yes

No

Unknown

2. Were any of these chest x-rays abnormal?
Yes

No

Unknown

2a. Date of first abnormal chest x-ray:
/

/

2b. For first abnormal chest x-ray, please check all that apply:
Report not available
Air space density
Air space opacity
Bronchopneumonia/pneumonia

Cannot rule out pneumonia
Consolidation
Cavitation
ARDS (acute respiratory distress syndrome)

Lung infiltrate
Interstitial infiltrate
Lobar infiltrate
Pleural Effusion

Empyema
Other

M. 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

08/26/2021

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

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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) or adults (MIS-A)
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

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N. ICD-10-CM codes Discharged Diagnoses (to be recorded in order of appearance)

ICD-10-CM codes not available:
1.

4.

7.

2.

5.

8.

3.

6.

9.

O. Pregnancy Information - To be completed for pregnant women only
1. Total # of pregnancies as of date of admission (Gravida, G):

2. Total # of pregnancies that resulted in a live birth as of date of admission (Parity, P):

Unknown

Unknown

3. Specify total # of fetuses for current pregnancy as of date of admission:

1

4. Specify gestational age in weeks as of date of admission:

Unknown

If gestational age in weeks unknown, specify trimester of pregnancy:
5. Indicate pregnancy status at discharge or death:

2

>3

1st (0 to 13 6/7 weeks)

Still pregnant

Unknown

2nd (14 0/7 to 27 6/7 weeks)

No longer pregnant

5a. If patient was pregnant on admission but no longer pregnant at
discharge, indicate pregnancy outcome at discharge:
Healthy newborn

3

3rd (28 0/7 to end)

Unknown

Unknown

5b. Pre-term live birth? (<37 weeks GA)
Yes

(If Healthy newborn, Ill newborn or Infant died, go to 5b.)

Pre-term delivery, gestational age in weeks:

No

Ill newborn

Unknown

Infant died
Miscarriage (intrauterine death at <20 weeks GA)
Stillbirth (intrauterine death at ≥20 weeks GA)
Abortion
Unknown
5c. If no longer pregnant, indicate date of delivery or end of pregnancy:

/

/

Unknown

P. 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

Patient

Proxy

4b. If patient < 9 yrs, specify vaccine type:

Combination of both
No

Unknown

Nasal Spray/FluMist
Yes, specific date unknown

No

Unknown

Yes, specific date unknown

Unknown type
Unsuccessful Attempt

Unknown type
Unsuccessful Attempt

No

Unknown

Not Checked

Unknown type
Unsuccessful Attempt

Date Unknown
Nasal Spray/FluMist

Combination of both

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

08/26/2021

Not Checked

Combination of both

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

/

Unsuccessful Attempt

Date Unknown

/

Injected Vaccine

Not Checked

Combination of both

Nasal Spray/FluMist

/

Not Checked

Date Unknown

/

Injected Vaccine

4a. If yes, specify dosage date information:

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

/

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Q. Additional Comments

08/26/2021

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