Case Report Form - Word

Form Approved

OMB Control No.: 0920-XXXX

Exp. date: XX/XX/XXXX

Triazole-resistant Aspergillus fumigatus case report form

Unique patient ID (DCIPHER): ________________

ARLN specimen ID: ________________ | ARLN isolate ID:________________ | ARLN patient ID:________________

Form completion data
Name of person completing this form: _______________________ Institution: _______________________ Email: ____________________ Telephone: ___________________ Date form completed: _________________ Date of incident specimen collection (DISC)*: ______-______-___________ (mm-dd-yyyy) *This is the earliest date that a patient had a positive test for triazole-resistant A. fumigatus
	A. Patient demographics
	1. Age at DISC: (use months or days if patient was aged <2 years)	________ □ years □ months □ days □ unknown
	2. Sex	□ Male □ Female □ other (specify): __________ □ unknown
	3. Ethnic origin	□ Hispanic or Latino □ not Hispanic or Latino □ unknown
	4. Race (select all that apply)	□ American Indian/Alaska Native □ Asian □ Black/African American □ Native Hawaiian/Pacific Islander □ White □ Unknown
	5. Patient's county of residence	_______________________ □ unknown
	6. Patient’s state, jurisdiction, or territory of residence	_______________________ □ unknown
	7. Patient’s country of residence (e.g., USA)	_______________________ □ unknown
	8. Healthcare facility name (Note: ‘healthcare facility’ refers to the facility where the patient’s incident specimen was collected)	_______________________ □ unknown
	9. Healthcare facility CMS ID #	_______________________ □ unknown

Public reporting burden of this collection of information is estimated to average 30 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-XXXX.

A. Patient Demographics (continued)
10. Healthcare facility ZIP code	_______________________ □ unknown
11. Healthcare facility state, jurisdiction, or territory	_______________________ □ unknown
12. Healthcare facility type	□ acute care hospital □ long-term acute care hospital (LTACH) □ skilled nursing facility with ventilated residents (vSNF) □ skilled nursing facility without ventilated residents (SNF) □ outpatient □ unknown □ other ________________________

B. Patient underlying risk factors & medical conditions present during the 2 years before DISC (unless other timeframe specified)
1. Cancer □ Yes □ No □ Unknown □ Hematologic malignancy specify type: _____________ □ Solid organ malignancy specify type:____________	3. Chronic pulmonary diagnosis □ Yes □ No □ Unknown □ Chronic obstructive pulmonary disease (COPD) or emphysema □ Bronchiectasis □ Cystic fibrosis □ Allergic bronchopulmonary aspergillosis (ABPA) □ Pulmonary fibrosis □ Asthma □ Interstitial Lung Disease □ Other chronic pulmonary diagnosis (specify):____________
2. HIV-infection □ Yes □ No □ Unknown If yes, choose one of the below Ever had CD4 < 200 cells/mm3 within past 6 months □ Yes □ No □ Unknown
4. Positive respiratory viral test in 30 days before DISC □ Yes □ No □ Unknown If yes, (select all that apply): □ SARS-CoV-2 (PCR or antigen test) □ antigen □ PCR □ unknown test type □ Influenza □ Other respiratory virus (specify) ________________	5. Transplant received within 2 years before DISC □ Yes □ No □ Unknown □ Solid organ transplant: □ Lung □ Heart □ Kidney □ Pancreas □ Liver □ Skin Graft □Other:___________________________ □ Hematopoietic stem cell transplant (HSCT)
6. Other selected conditions: □ Yes □ No □ Unknown □ Diabetes mellitus □ End stage renal disease/dialysis □ Autoimmune disease(s) or inherited immunodeficiency(-ies) (specify) : _________________________ □ Medications/therapies that weaken the immune system (specify): ____________________________________________ ____________________________________________ ____________________________________________ □ Cirrhosis	7. Other potentially relevant clinical information? □ Yes (specify below) □ No □ Unknown ________________________________ ________________________________ ________________________________ ________________________________ ________________________________

C. Patient diagnosis and outcomes
1. According to treating clinicians, which clinical syndrome(s) related to Aspergillus did the patient have?	□ Invasive pulmonary aspergillosis (IPA) □ Other disease/syndrome(s) related to A. fumigatus: ___________________ □ Aspergillus was not believed to be causing clinical illness or is not mentioned in medical records □ unknown
2. Was the patient hospitalized at an acute care hospital in the 30 days before to 30 days after DISC?	□ yes □ no □ unknown If yes, dates of admission of hospitalization most proximal to DISC, Admission date: ______-______-___________ (mm-dd-yyyy) Discharge date: ______-______-___________ (mm-dd-yyyy) □ still hospitalized If yes, Received ICU-level care in the 14 days before DISC?: □ yes □ no □ unknown Received ICU-level care in the 14 days after DISC?: □ yes □ no □ unknown Discharge ICD-10 diagnosis code(s): _________________________________
3. Died within 30 days after DISC?	□ no □ yes, date of death _______ - _______- ______________ (mm-dd-yyyy) Cause(s) of death _________________ □ unknown

	D. Antifungal treatment: Please use the table below to indicate antifungal drugs that the patient received during the 60 days before to 30 days after the DISC.
Select one of the following to complete each row of the table
Amphotericin B lipid complex (ABLC) Liposomal Amphotericin B (L-AmB) Amphotericin B coloidal dispersion (ABCD) Anidulafungin (ANF)		Caspofungin (CAS) Fluconazole (FLC)* Flucytosine (5FC) Isavuconazole (ISA)	Itraconazole (ITC) Micafungin (MFG) Posaconazole (PSC) Voriconazole (VRC)	Other drug (specify): ________________________ Unknown drug (UNK) *Indicates not mold-active

Drug Abbrev	b. First date given (mm-dd-yyyy)	c. Last date given (mm-dd-yyyy)	d. Indication
	___ ___ - ___ ___ - ___ ___ ___ ___ □ Start date unknown □ Start date was >60 days before DISC	___ ___ - ___ ___ - ___ ___ ___ ___ □ Still on treatment at time CRF completed □ Stop date unknown	□ Prophylaxis □ Treatment for Aspergillus □ Treatment for non-Aspergillus infection
	___ ___ - ___ ___ - ___ ___ ___ ___ □ Start date unknown □ Start date was >60 days before DISC	___ ___ - ___ ___ - ___ ___ ___ ___ □ Still on treatment at time CRF completed □ Stop date unknown	□ Prophylaxis □ Treatment for Aspergillus □ Treatment for non-Aspergillus infection
	___ ___ - ___ ___ - ___ ___ ___ ___ □ Start date unknown □ Start date was >60 days before DISC	___ ___ - ___ ___ - ___ ___ ___ ___ □ Still on treatment at time CRF completed □ Stop date unknown	□ Prophylaxis □ Treatment for Aspergillus □ Treatment for non-Aspergillus infection
	___ ___ - ___ ___ - ___ ___ ___ ___ □ Start date unknown □ Start date was >60 days before DISC	___ ___ - ___ ___ - ___ ___ ___ ___ □ Still on treatment at time CRF completed □ Stop date unknown	□ Prophylaxis □ Treatment for Aspergillus □ Treatment for non-Aspergillus infection
	___ ___ - ___ ___ - ___ ___ ___ ___ □ Start date unknown □ Start date was >60 days before DISC	___ ___ - ___ ___ - ___ ___ ___ ___ □ Still on treatment at time CRF completed □ Stop date unknown	□ Prophylaxis □ Treatment for Aspergillus □ Treatment for non-Aspergillus infection
	___ ___ - ___ ___ - ___ ___ ___ ___ □ Start date unknown □ Start date was >60 days before DISC	___ ___ - ___ ___ - ___ ___ ___ ___ □ Still on treatment at time CRF completed □ Stop date unknown	□ Prophylaxis □ Treatment for Aspergillus □ Treatment for non-Aspergillus infection
	___ ___ - ___ ___ - ___ ___ ___ ___ □ Start date unknown □ Start date was >60 days before DISC	___ ___ - ___ ___ - ___ ___ ___ ___ □ Still on treatment at time CRF completed □ Stop date unknown	□ Prophylaxis □ Treatment for Aspergillus □ Treatment for non-Aspergillus infection

F. Supplemental patient interview form:

Note that “you” in these questions refers to the patient.

1. Person interviewed

□ Patient □ Someone other than the patient, (specify relationship to patient): _______________

2. What was your job or occupation before [DISC]?

___________________________ □ Unemployed □ Retired □ N/A

□ Refused □ Unknown

3. Did you travel outside of

[healthcare facility state] within 3 months before [DISC]?

(note: if healthcare facility is in a different state from patient’s residence, then please count time spent in the patient’s home state as “travel”)

List state(s), territory(-ies), jurisdiction(s), country(-ies)

□ Yes □ No □ Unknown

__________________________________________________________________

__________________________________________________________________

4. Did you perform any of the following activities during the 90 days before [DISC]

Gardening	□ Yes □ No □ Unknown
Handling compost	□ Yes □ No □ Unknown
Handling a fungicide product	□ Yes □ No □ Unknown
Spending time on a farm	□ Yes □ No □ Unknown
If patient spent time on a farm in 90 days before DISC, describe location, type of crop(s) grown (if applicable), and activities performed on farm: _____________________________ _____________________________ _____________________________

Additional comments: _____________________________________________________________________________________________

_____________________________________________________________________________________________