National Adenovirus Type Reporting System (NATRS) Form

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Overview

REPORT FORM
STATE FIPS CODE LIST
HAdV Species and Types
Other

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Sheet 1: REPORT FORM

National Adenovirus Type Reporting System (NATRS) Report Form

Code

Specimen Type

1

NP and/or OP swab

2

NP and/or OP wash

CDC ONLY

HAdV Positive Test Results

Adenovirus 1

Adenovirus 2

Optional Information

3

Sputum

NATRSid

CDCID

Date of Report to CDC

Patient Num.*

Specimen Num.*

Reporting Lab

Age (# Only)**

Age Type (Months or Years)**

Sex (M/F/U)

State of Residence

Specimen Type (see legend)

Specimen Type-Specified

Specimen Collection Date (mm/dd/yyyy)

Number of AdV Detected

AdV Species (A-G)

AdV Type

AdV Species (A-G)

AdV Type

HAdV Species/Type Determined by (see legend)

Type Determined by Other (please specify)

Coinfection detected (Y/N/U)

Coinfection(s) Detected (please specify)

Fatal (Y/N/U)

Hospitalized (Y/N/U)

Outbreak (Y/N/U)

Outbreak Type (see legend)

Binder, Alison (CDC/OID/NCIRD) (CTR): ADD VARIABLE Capture if specimen sent elsewhere for (further) typing Specimen sent elsewhere for typing (Y/N/U)

Comments/Other

4

Tracheal Aspirate

Primary Specimen

5

Bronchoalveolar Lavage

or Culture Isolate

6

Pleural Fluid

7

Ocular Swab (e.g. conjunctival, eye)

10

Stool

11

Tissue(Specify)__________

12

Serum

13

Blood

14

Urine

8

Other(Specify)_________________

9

Unknown

Code

Adenovirus Source

1

Primary Specimen

2

Culture Isolate

3

Nucleic Acid

8

Other (specify) _______

9

Unknown

Code

Human Adenovirus Species/Type Determined by

1

Sequencing Hexon Gene

2

Sequencing Fiber Gene

3

Next Gen Sequencing

4

Sequencing Other

5

Real time PCR

6

Commercial Molecular Assay (ie. GenMark)

7

Serum Neutralization

8

Other(Specify)_________________

9

Unknown

10

Sequencing Hexon and Fiber Gene

Code

Outbreak Type

1

Hospital

2

School

3

Daycare

4

Long Term Care Facility

5

Military

6

Community

8

Other (specify) _______

9

Unknown

*

Please enter unique patient level number and laboratory specimen number(s), i.e patient num. 1, specimen num. 1, 2, 3, etc. If entering >1 specimen per patient, epidemiologic and clinical data may be entered for the first line only

**

If patient age is 0-2 years, please list age in months

Date of Report

Reporting Official

Title

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-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0004).

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Sheet 2: STATE FIPS CODE LIST

CODE	ABBR	STATENAME
1	AL	ALABAMA
2	AK	ALASKA
4	AZ	ARIZONA
5	AR	ARKANSAS
6	CA	CALIFORNIA
8	CO	COLORADO
9	CT	CONNECTICUT
10	DE	DELAWARE
11	DC	DISTRICT OF COLUMBIA
12	FL	FLORIDA
13	GA	GEORGIA
15	HI	HAWAII
16	ID	IDAHO
17	IL	ILLINOIS
18	IN	INDIANA
19	IA	IOWA
20	KS	KANSAS
21	KY	KENTUCKY
22	LA	LOUISIANA
23	ME	MAINE
24	MD	MARYLAND
25	MA	MASSACHUSETTS
26	MI	MICHIGAN
27	MN	MINNESOTA
28	MS	MISSISSIPPI
29	MO	MISSOURI
30	MT	MONTANA
31	NE	NEBRASKA
32	NV	NEVADA
33	NH	NEW HAMPSHIRE
34	NJ	NEW JERSEY
35	NM	NEW MEXICO
36	NY	NEW YORK
37	NC	NORTH CAROLINA
38	ND	NORTH DAKOTA
39	OH	OHIO
40	OK	OKLAHOMA
41	OR	OREGON
42	PA	PENNSYLVANIA
44	RI	RHODE ISLAND
45	SC	SOUTH CAROLINA
46	SD	SOUTH DAKOTA
47	TN	TENNESSEE
48	TX	TEXAS
49	UT	UTAH
50	VT	VERMONT
51	VA	VIRGINIA
53	WA	WASHINGTON
54	WV	WEST VIRGINIA
55	WI	WISCONSIN
56	WY	WYOMING
60	AS	AMERICAN SAMOA
64	FM	FEDERATED STATES OF MICRONESIA
66	GU	GUAM
69	MP	NORTHERN MARIANA ISLANDS
70	PW	PALAU
72	PR	PUERTO RICO
74	UM	U.S. MINOR OUTLYING ISLANDS
78	VI	VIRGIN ISLANDS
99	UNK	UNKNOWN

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Sheet 3: HAdV Species and Types

CODE	HAdV Species
1	A
2	B
3	C
4	D
5	E
6	F
7	B/E
8	G
CODE	HAdV Type
1	1
2	2
3	3
4	4
5	5
6	6
7	7
8	8
9	9
10	10
11	11
12	12
13	13
14	14
15	15
16	16
17	17
18	18
19	19
20	20
21	21
22	22
23	23
24	24
25	25
26	26
27	27
28	28
29	29
30	30
31	31
32	32
33	33
34	34
35	35
36	36
37	37
38	38
39	39
40	40
41	41
42	42
43	43
44	44
45	45
46	46
47	47
48	48
49	49
50	50
51	51
52	52
53	53
54	54
55	55
56	56
57	57
99	Undetermined

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Sheet 4: Other

CODE	Yes/No/Unknown
1	Yes
2	No
3	Unknown
CODE	Age Type
1	Months
2	Years
CODE	Specimen
1	Primary
2	Culture Isolate
CODE	Sex
1	Male
2	Female
9	Unknown
CODE	Adenovirus Source
1	Primary Specimen
2	Culture Isolate
3	Nucleic Acid
8	Other (specify) _______
9	Unknown
CODE	Specimen Type
1	NP and/or OP swab
2	NP and/or OP wash
3	Sputum
4	Tracheal Aspirate
5	Bronchoalveolar Lavage
6	Pleural Fluid
7	Ocular Swab (e.g. conjunctival, eye)
10	Stool
11	Tissue(Specify)__________
12	Serum
13	Blood
14	Urine
8	Other(Specify)_________________
9	Unknown
CODE	Outbreak Type
1	Hospital
2	School
3	Daycare
4	Long Term Care Facility
5	Military
6	Community
8	Other (specify) _______
9	Unknown
CODE	Typing Method
1	Sequencing Hexon Gene
2	Sequencing Fiber Gene
3	Next Gen Sequencing
4	Sequencing Other
5	Real time PCR
6	Commercial Molecular Assay (ie. GenMark)
7	Serum Neutralization
8	Other(Specify)_________________
9	Unknown
10	Sequencing Hexon and Fiber Gene