Aggregate case counts of person exposed to Highly Pathog

Form Approved
OMB No. 0920-1011
Exp. Date 01/31/2023

Aggregate counts of persons exposed to highly pathogenic avian influenza (HPAI)
State:
Report Date:

(mm/dd/yyyy)

Report for MMWR week: _____ (MMWR weeks run from Sunday to following Saturday)
USDA/
Contract
Responders*

State or
Producer
Responders*

Not affiliated
with Response
(e.g. farm
owners,
workers)

Other, specify:
____________
____________

Total

Total number of individuals exposed and intended to be
actively monitored (cumulative for the current calendar
year)
Total number of individuals whose monitoring period is
complete
Total number of individuals lost to follow-up before the
monitoring period was complete
Total number of individuals currently actively monitoring**
Total ill¥¥ in past week
Total tested in past week
*an individual who participated in the confirmation, depopulation, and/or decontamination of the site.
**Actively monitored can either be daily active monitoring (DAM) or a modified form of active monitoring (including day 0, 5, and 10) as long as contact
with the individual has been made via in person, phone, text, or email.
¥¥compatible with HPAI including any of the following symptoms: fever or feeling feverish/chills; cough; sore throat; runny or stuffy nose; eye tearing,
redness, irritation (“pink eye”); sneezing; difficulty breathing; shortness of breath; fatigue (feeling very tired); muscle or body aches; headaches; nausea;
vomiting; diarrhea; seizures; or rash

Please send this data to the Influenza Division at CDC (email: [email protected])
Public reporting burden of this collection of information is estimated to average 10 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 (0920-1011)