Form CS340190-A 2022-23 FluSurv-NET Influenza Hospitalization Surveillan

2023-24 Influenza
Hospitalization Surveillance Network (FluSurv-NET)
Case Report Form

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

FORM APPROVED
OMB NO. 0920-0978
FluSurv-NET Case ID:

COVID-NET Case ID:

RSV-NET Case ID:

A. Patient Data – THIS INFORMATION IS NOT SENT TO CDC
First Name:

Last 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:

Pharmacy of Record:

Pharmacy Phone:

Pharmacy Fax:

No PCP

Pharmacy Address:
Site Use 1:

Site Use 2:

Site Use 3:

CDCTrack:

B. Abstractor Information – THIS INFORMATION IS NOT SENT TO CDC
1. Abstractor Name:

2. Date of Abstraction:
C. Enrollment Information

1. Case Classification:
Surveillance Discharge Audit

2. State:

8. Race (select all that apply):
White
Black or African American
Asian
Native Hawaiian or other
Pacific Islander
American Indian or Alaska Native
Multiracial, not otherwise specified
Not specified

9. Ethnicity:
Hispanic or Latino
Non-Hispanic/Latino
Not Specified
10. Was patient discharged from any
hospital within 1 week prior to the
current admission date?
Yes
No
Unknown

14. Was patient transferred from another hospital?
Yes
No
Unknown

4. Case Type:
Pediatric
Adult

3. County:

5. Date of Birth:

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

14a. Transfer Hospital ID:

6. Age:
7. Sex:
Years
Male
Months (if < 1 yr)
Female
Days (if < 1 month)
12. Pregnant? (15-49 years of age only):
Yes
No/Unknown
Not applicable
(male/pregnant outside of applicable age range)

13. Hospital ID Where Patient Treated:
13a. Admission Date:
13b. Discharge Date:

14b. Transfer Hospital Admission Date:
14c. Transfer Date:

15. Where did the patient reside at the time of hospitalization? (Indicate TYPE of residence.)
Private residence
Private residence with services
Homeless/Shelter/Temporary housing
Nursing home/Skilled nursing facility

Substance abuse treatment center
Hospitalized at birth
Rehabilitation facility
Corrections facility

Hospice
Assisted living/Residential care
LTACH
Group/Retirement home

Psychiatric facility
Other long term care facility
Other, specify:
Unknown

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).
07/05/2023

Page 1 of 9

CS340190-A

Case ID:
D. Influenza Testing Results (can add up to 4 test results in database)
1. Test 1:

Rapid Antigen
Molecular Assay

1a. Result:

Flu A (no subtype)
2009 H1N1
H1, Unspecified

Rapid Molecular Assay
Viral Culture
H1, Seasonal
H1
H3

Flu A, Unsubtypable
Flu B (no lineage)
Flu B, Victoria

1b. Specimen collection date:

Serology
Fluorescent Antibody

Method Unknown

Flu B, Yamagata
Flu A & B
Flu A/B (not distinguished)

Unknown Type
Negative
H3N2v

1c. Specimen ID:

2. Test 2:

Rapid Antigen
Molecular Assay

2a. Result:

Flu A (no subtype)
2009 H1N1
H1, Unspecified

1d. Testing facility ID:

Rapid Molecular Assay
Viral Culture
H1, Seasonal
H1
H3

Flu A, Unsubtypable
Flu B (no lineage)
Flu B, Victoria

2b. Specimen collection date:

Serology
Fluorescent Antibody

Method Unknown

Flu B, Yamagata
Flu A & B
Flu A/B (not distinguished)

Unknown Type
Negative
H3N2v

2c. Specimen ID:

3. Test 3:

Rapid Antigen
Molecular Assay

3a. Result:

Flu A (no subtype)
2009 H1N1
H1, Unspecified

Flu A, Unsubtypable
Flu B (no lineage)
Flu B, Victoria

3b. Specimen collection date:

Other, please specify:

2d. Testing facility ID:

Rapid Molecular Assay
Viral Culture
H1, Seasonal
H1
H3

Other, please specify:

Serology
Fluorescent Antibody

Method Unknown

Flu B, Yamagata
Flu A & B
Flu A/B (not distinguished)

Unknown Type
Negative
H3N2v

3c. Specimen ID:

Other, please specify:

3d. Testing facility ID:

E. Other Interventions and ICU
1. BiPAP or CPAP?

Yes

No

3. Invasive mechanical ventilation?

Yes

No

5. Supplemental Oxygen?
Yes

No

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

Unknown

Unknown

7. Was the patient admitted to an intensive care unit (ICU)?
7a. Date of 1st ICU Admission:

4. ECMO?

Unknown

Yes

No

Yes

No

Unknown

Unknown

Yes
No
Unknown
6. Renal Replacement Therapy (RRT) or Dialysis?
Includes Peritoneal Dialysis (PD), Hemodialysis (HD), Continuous Venovenous Hemofiltration (CVVH),
Continuous Venovenous Hemodialysis (CVVHD), and Slow Continuous Ultrafiltration (SCUF)
Yes
Unknown

No

Unknown
7b. Date of 1st ICU Discharge:

Unknown

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/Temporary housing
Nursing home/Skilled nursing facility
Substance abuse treatment center
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:

07/05/2023

Page 2 of 9

CS340190-A

Case ID:
G. Admission and Patient History
1. Reason for admission:
Psychiatric admission needing acute medical care
Newborn/Hospitalized at birth
Trauma

Influenza-related illness
OB/Labor and delivery admission
Inpatient surgery/procedures

Other, specify:
Unknown

2. Acute signs/symptoms present at admission (began or worsened within 2 weeks prior to admission) (Select all that apply):
Non-respiratory symptoms
Abdominal pain
Altered mental status/
confusion

None of the below signs/symptoms

Anosmia/Decreased smell
Chest pain/tightness
Conjunctivitis

Diarrhea
Dysgeusia/Decreased taste
Fatigue

Fever/chills
Headache
Muscle aches/myalgias

Cough
Hemoptysis/bloody
sputum

 hortness of breath/
S
respiratory distress
Sore throat

URI/ILI
Wheezing

Hypothermia
Inability to eat/poor feeding
Irritability/fussiness/
excess crying

 ethargy/decreased activity
L
Nasal flaring/grunting/
retractions

Stridor/decreased
vocalization
Tachypnea/increased work
of breathing

Nausea/vomiting
Rash
Seizures

Respiratory symptoms
Chest congestion
Congested/runny nose
For cases < 12 years
Apnea
Cyanosis
Dehydration/decreased
urine output

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

Inch
Cm
Unknown

Former

No/Unknown

Former

No/Unknown

9. Alcohol abuse:
Current

Lbs
Kg
Unknown

5. Weight:

Not applicable

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

Unknown

8. Environmental tobacco smoke exposure (for pediatric patients < 12 years):

7. Smoker (tobacco):
Current

Unknown

Yes

No

Unknown

10. Substance abuse:
Current

Former

No/Unknown

11. Substance Abuse Type (current use only) (Select all that apply):
Cocaine
IVDU
Opioids

Polysubstance abuse - not otherwise specified
Methamphetamines
Marijuana

12. Code status on admission:

07/05/2023

Full code

DNR/DNI/CMO

Other, specify:
Unknown

Unknown

Page 3 of 9

CS340190-A

Case ID:
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:

Yes

No/Unknown

1b. Chronic Lung Disease:
Yes
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
1c. Chronic Metabolic Disease:
Yes
No/Unknown
Adrenal Disorders (Addison’s disease, adrenal insufficiency,
Cushing syndrome, congenital adrenal hyperplasia)
Diabetes mellitus (DM)
Glycogen or other storage diseases (See list)
Hyper/Hypo- function of pituitary gland
Inborn errors of metabolism (See list)
Metabolic syndrome
Parathyroid dysfunction (hyperparathyroidism, hypoparathyroidism)
Thyroid dysfunction (Grave’s disease, Hashimoto’s disease, hyperthyroidism,
hypothyroidism)
1d.Blood Disorders/Hemoglobinopathy:
Yes
No/Unknown
Alpha thalassemia
Aplastic anemia
Beta thalassemia
Coagulopathy (Factor V Leiden, Von Willebrand disease (VWD), see list)
Hemoglobin S-beta thalassemia
Leukopenia
Myelodysplastic syndrome (MDS)
Neutropenia
Pancytopenia
Polycythemia vera
Sickle cell disease
Splenectomy/Asplenia
Thrombocytopenia

07/05/2023

Yes

No

Unknown

1e. Cardiovascular Disease:
Yes
No/Unknown
Aortic aneurysm (AAA), history of
Aortic/Mitral/Tricuspid/Pulmonic valve replacement, history of
Aortic regurgitation (AR)
Aortic stenosis (AS)
Atherosclerotic cardiovascular disease (ASCVD)
Atrial fibrillation (AFib)
Atrioventricular (AV) blocks
Automated implantable devices (AID/AICD)/Pacemaker
Bundle branch block (BBB/RBBB/LBBB)
Cardiomyopathy
Carotid stenosis
Cerebral vascular accident (CVA)/Incident/Stroke, history of
Congenital heart disease (Specify)
Atrial septal defect
Pulmonic stenosis
Tetralogy of Fallot
Ventricular septal defect
Other, specify:
Coronary artery bypass grafting (CABG), history of
Coronary artery disease (CAD)
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

Page 4 of 9

CS340190-A

Case ID:
H. Underlying Medical Conditions (continued)
1f. Neurologic Disorder:
Yes
Amyotrophic lateral sclerosis (ALS)
Cerebral palsy
Cognitive dysfunction
Dementia/Alzheimer’s disease
Developmental delay
Down syndrome/Trisomy 21
Edward’s syndrome/Trisomy 18
Epilepsy/seizure/seizure disorder
Mitochondrial disorder (See list)
Multiple sclerosis (MS)
Muscular dystrophy (See list)
Myasthenia gravis (MG)
Neural tube defects/Spina bifida (See list)
Neuropathy
Parkinson’s disease
Plegias/Paralysis/Quadriplegia
Scoliosis/Kyphoscoliosis
Traumatic brain injury (TBI), history of

No/Unknown

1g. History of Guillain-Barre Syndrome:

No/Unknown

Yes

1h. Immunocompromised Condition:
Yes
No/Unknown
AIDS or CD4 count < 200
Complement deficiency (See list)
Graft vs. host disease (GVHD)
HIV infection
Immunoglobulin deficiency/immunodeficiency (See list)
Immunosuppressive therapy
(within the 12 months previous to admission) (see instructions):
If yes, for what condition?
Leukemia*
Lymphoma/Hodgkins/Non-Hodgkins (NHL)*
Metastatic cancer*
Multiple myeloma*
Solid organ malignancy*
If yes, which organ?
Steroid therapy (within 2 weeks of admission) (see instructions)
Transplant, hematopoietic stem cell (bone marrow transplant (BMT),
peripheral stem cell transplant (PSCT)), history of
Transplant, solid organ (SOT), history of
*Current/in treatment or diagnosed in last 12 months
1i. Renal Disease
Yes
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)
1j. Any Obesity:
Yes
Obese
Severely/morbidly obese (ADULTS ONLY)

No/Unknown

1k. Post-partum (two weeks or less):

No/Unknown

07/05/2023

Yes

1l. G
 astrointestinal/Liver Disease
(Do Not Record GERD):
Yes
No/Unknown
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)
1m. Rheumatologic/Autoimmune/Inflammatory
Conditions (Do Not Record OA):
Yes
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

1n. Mental Health Conditions:
Bipolar disorder
Depression
Schizophrenia spectrum disorder

Yes

No/Unknown

1o. Hypertension (HTN):

Yes

No/Unknown

1p. Other:
Yes
Feeding tube dependent (PEG, see list)
Trach dependent/Vent dependent
Wheelchair dependent
Other, specify:

No/Unknown

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 (gestational age < 37 weeks at birth for patients < 2 years)
If yes, specify gestational age at birth in weeks:
Unknown gestational age at birth

Page 5 of 9

CS340190-A

I. Bacterial Pathogens (can add additional culture results to the study database) – Sterile or respiratory site only
Were any culture tests performed within 3 days prior to or 3 days following admission?

Yes

No

Unknown

Specimen 1
1a. If yes, what is the specimen source?
Blood
Bone/joint aspirate
Bronchoalveolar lavage (BAL),
bronchial aspirate/wash
1b. Date of specimen collection for culture

Cerebrospinal fluid (CSF)
Endotracheal/tracheal aspirate
Peritoneal or abdominal fluid/ascites
1c. Result of culture:
Positive
Negative
Unknown

Pleural fluid
Sputum

Wound - Group A Streptococcus (only)
Other, specify:

1d. If positive, what pathogen was identified?
Bacteria, specify:
Aspergillus (fungus)
Mucormycosis (fungus)

1e. If Staphylococcus aureus, specify:
Methicillin resistant (MRSA)
Methicillin sensitive (MSSA)
Sensitivity unknown

Specimen 2
2a. If yes, what is the specimen source?
Blood
Bone/joint aspirate
Bronchoalveolar lavage (BAL),
bronchial aspirate/wash
2b. Date of specimen collection for culture

Cerebrospinal fluid (CSF)
Endotracheal/tracheal aspirate
Peritoneal or abdominal fluid/ascites
2c. Result of culture:
Positive
Negative
Unknown

Pleural fluid
Sputum

Wound - Group A Streptococcus (only)
Other, specify:

2d. If positive, what pathogen was identified?
Bacteria, specify:
Aspergillus (fungus)
Mucormycosis (fungus)

2e. If Staphylococcus aureus, specify:
Methicillin resistant (MRSA)
Methicillin sensitive (MSSA)
Sensitivity unknown

Specimen 3
3a. If yes, what is the specimen source?
Blood
Bone/joint aspirate
Bronchoalveolar lavage (BAL),
bronchial aspirate/wash
3b. Date of specimen collection for culture

Cerebrospinal fluid (CSF)
Endotracheal/tracheal aspirate
Peritoneal or abdominal fluid/ascites
3c. Result of culture:
Positive
Negative
Unknown

Pleural fluid
Sputum

Wound - Group A Streptococcus (only)
Other, specify:

3d. If positive, what pathogen was identified?
Bacteria, specify:
Aspergillus (fungus)
Mucormycosis (fungus)

3e. If Staphylococcus aureus, specify:
Methicillin resistant (MRSA)
Methicillin sensitive (MSSA)
Sensitivity unknown

Specimen 4
4a. If yes, what is the specimen source?
Blood
Bone/joint aspirate
Bronchoalveolar lavage (BAL),
bronchial aspirate/wash
4b. Date of specimen collection for culture

07/05/2023

Cerebrospinal fluid (CSF)
Endotracheal/tracheal aspirate
Peritoneal or abdominal fluid/ascites
4c. Result of culture:
Positive
Negative
Unknown

Pleural fluid
Sputum

Wound - Group A Streptococcus (only)
Other, specify:

4d. If positive, what pathogen was identified?
Bacteria, specify:
Aspergillus (fungus)
Mucormycosis (fungus)

Page 6 of 9

4e. If Staphylococcus aureus, specify:
Methicillin resistant (MRSA)
Methicillin sensitive (MSSA)
Sensitivity unknown

CS340190-A

Case ID:
J. Viral Pathogens
1.Was patient tested for any of the following viral respiratory pathogens within 14 days prior to admission or ≤3 days after admission?

Yes

1a. 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 229E

Yes, positive

Yes, negative

Not tested/Unknown

Date:

1j. Coronavirus HKU1

Yes, positive

Yes, negative

Not tested/Unknown

Date:

1k. Coronavirus NL63

Yes, positive

Yes, negative

Not tested/Unknown

Date:

1l. Coronavirus OC43

Yes, positive

Yes, negative

Not tested/Unknown

Date:

1m. Coronavirus SARS-CoV-2

Yes, positive

Yes, negative

Not tested/Unknown

Date:

1n. Coronavirus (not further specified)

Yes, positive

Yes, negative

Not tested/Unknown

Date:

No

Unknown

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

No

Baloxavir marboxil (Xofluza)
Oseltamivir (Tamiflu)

1b. Start date:
2a. Treatment 2:

Yes

Unknown
Peramivir (Rapivab)
Zanamivir (Relenza)

Other, specify:
Unknown

Peramivir (Rapivab)
Zanamivir (Relenza)

Other, specify:
Unknown

Unknown
Baloxavir marboxil (Xofluza)
Oseltamivir (Tamiflu)

2b. Start date:

Unknown

3. Vasopressor use?
Yes
No
Unknown
(Common vasopressors are Dobutamine, Dopamine, Epinephrine, Milrinone, Neosynephrine, Norepinephrine, Vasopressin)
4. Additional Treatment Comments:
L. Chest X-ray – Based on radiology report only
1. Was a chest x-ray taken within 3 days after admission?
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

07/05/2023

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

Page 7 of 9

Infiltrate (lung, interstitial, other)
Lobar infiltrate
Pleural Effusion

Empyema
Other

CS340190-A

Case ID:
M. Discharge Summary
1. Did the patient have any of the following new diagnoses at discharge? (select all that apply)

No discharge summary available

Acute complication of sickle cell

Yes

No/Unknown

Disseminated intravascular coagulation (DIC)

Yes

No/Unknown

Acute encephalopathy/encephalitis

Yes

No/Unknown

Guillain-Barre syndrome

Yes

No/Unknown

Acute liver failure

Yes

No/Unknown

Hemophagocytic syndrome

Yes

No/Unknown

Acute myocardial infarction

Yes

No/Unknown

Invasive pulmonary aspergillosis

Yes

No/Unknown

Acute myocarditis

Yes

No/Unknown

Kawasaki disease

Yes

No/Unknown

Acute renal failure/acute kidney injury

Yes

No/Unknown

No/Unknown

Yes

No/Unknown

Acute respiratory failure

Yes

No/Unknown

Mucormycosis
Multisystem inflammatory syndrome in
children (MIS-C) or adults (MIS-A)

Yes

Acute respiratory distress syndrome (ARDS)

Yes

No/Unknown

Asthma exacerbation

Yes

No/Unknown

Other thrombosis/embolism/coagulopathy

Yes

No/Unknown

Atrial fibrilation (Afib) new-onset
or paroxysmal/chronic

Pneumonia

Yes

No/Unknown

Yes

No/Unknown

Pulmonary embolism (PE)

Yes

No/Unknow

Bacteremia

Yes

No/Unknown

Reye’s Syndrome

Yes

No/Unknown

Yes

No/Unknown

Bronchiolitis

Yes

No/Unknown

Rhabdomyolysis

Bronchitis

Yes

No/Unknown

Sepsis

Yes

No/Unknown

Cardiac arrest

Yes

No/Unknown

Seizures

Yes

No/Unknown

Yes

No/Unknown

Chronic lung disease of prematurity/BPD

Yes

No/Unknown

Stroke (CVA)

Congestive heart failure exacerbation

Yes

No/Unknown

Supraventricular tachycardia (SVT)

Yes

No/Unknown

COPD exacerbation

Yes

No/Unknown

Toxic shock syndrome (TSS)

Yes

No/Unknown

Deep vein thrombosis (DVT)

Yes

No/Unknown

Ventricular fibrillation (Vfib)

Yes

No/Unknown

Diabetic ketoacidosis

Yes

No/Unknown

Ventricular tachycardia (V-tach)

Yes

No/Unknown

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

Yes

No

1.

4.

7.

2.

5.

8.

3.

6.

9.

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

Unknown

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

1
2
3
> 3
Unknown

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

Unknown

4. Specify gestational age in weeks as of date of admission:
If gestational age in weeks unknown, specify trimester of pregnancy:

Unknown
1st (0 to 13 6/7 weeks)
2nd (14 0/7 to 27 6/7 weeks)

3rd (28 0/7 to end)
Unknown

5. Pregnancy complications during current pregnancy? (Select all that apply):
None
Gestational diabetes

Pre-eclampsia
Pregnancy-induced hypertension (PIH)

6. Indicate pregnancy status at discharge or death:

Still pregnant

Intrauterine growth restriction (IUGR)
Unknown
No longer pregnant

6a. If patient was pregnant on admission but no longer pregnant at discharge, indicate
pregnancy outcome at discharge. (If multiple fetuses, indicate outcome at discharge for
each fetus in the database separately.)
Healthy newborn
(if Healthy newborn, ill newborn or infant died, go to 6b.)
Ill newborn
Infant died
Miscarriage (intrauterine death at < 20 weeks GA)
Stillbirth (intrauterine death at ≥ 20 weeks GA)
Abortion
Unknown

}

6c. If no longer pregnant, indicate date of delivery or end of pregnancy:

07/05/2023

Unknown

6b. Pre-term live birth? (< 37 weeks GA)
Yes
No
Unknown

Preterm delivery, gestational age in weeks:

Unknown

Page 8 of 9

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Case ID:
P. Influenza Vaccination History
Specify vaccination status and date(s) by source:
No
Unknown

Yes, full date known
Yes, specific date unknown

1. Medical Chart:
1a. If yes, specify dosage date information:

Date Unknown

1b. If patient < 9 yrs, specify vaccine type:

Injected Vaccine

2. Vaccine Registry:

Yes, full date known
Yes, specific date unknown

Nasal Spray/FluMist

Unknown type

Not Checked
Unsuccessful Attempt

Date Unknown

2b. If patient < 9 yrs, specify vaccine type:

Injected Vaccine

3. Primary Care Provider /LTCF:

Yes, full date known
Yes, specific date unknown

Nasal Spray/FluMist

Combination of both

No
Unknown

3a. If yes, specify dosage date information:

Unknown type

Not Checked
Unsuccessful Attempt

Date Unknown

3b. If patient < 9 yrs, specify vaccine type:

Injected Vaccine

4. Interview:

Yes, full date known
Yes, specific date unknown

Nasal Spray/FluMist

Combination of both

No
Unknown

4a. If yes, specify dosage date information:
4b. If patient < 9 yrs, specify vaccine type:

Combination of both

No
Unknown

2a. If yes, specify dosage date information:

Patient
Proxy

Not Checked
Unsuccessful Attempt

Unknown type

Not Checked
Unsuccessful Attempt

Date Unknown
Injected Vaccine

Nasal Spray/FluMist

Combination of both

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

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:

Unknown type

Date Unknown

Q. Additional Comments

07/05/2023

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CS340190-A