Form CDC 55.90 CDC 55.90 Enterovirus Surveillance System Report Form

---

Overview

REPORT FORM
CODES

---

Sheet 1: REPORT FORM

National Enterovirus Surveillance System

Report Form

Form Approved OMB No. 0920-0004

Reporting Lab:

Lab ID:

Report Date (m/d/y):

Positive Test Results

Enterovirus 1

Enterovirus 2

Enterovirus 3

Age

Age Type

Sex

State/Territory of Residence

Illness Outcome

Number of Enteroviruses Detected

Enterovirus

Nucleic Acid Extract?

Source Specimen

Specimen Date (m/d/y)

Enterovirus

Nucleic Acid Extract?

Source Specimen

Specimen Date (m/d/y)

Enterovirus

Nucleic Acid Extract?

Source Specimen

Specimen Date (m/d/y)

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).

CDC 55.9 Rev.01/2014

---

Sheet 2: CODES

CODES FOR DATA ENTRY
AGE			AGE TYPE				STATE OR TERRITORY				ENTEROVIRUS			NUCLEIC ACID EXTRACT SPECIMEN
CODE	AGE		CODE	ABBR	Type		CODE	ABBR	State		AGENT	SEROTYPE		CODE	Nucleic Acid Extract?
0	0		0	D	Days		1	AL	Alabama		299	Coxsackievirus A Type Unknown		0	No
1	1		1	M	Months		2	AK	Alaska		201	Coxsackievirus A1		1	Yes
2	2		2	Y	Years		4	AZ	Arizona		210	Coxsackievirus A10		9	Unknown
3	3		9	U	Unknown		5	AR	Arkansas		211	Coxsackievirus A11
4	4						6	CA	California		212	Coxsackievirus A12		SPECIMEN TYPE
5	5		SEX				8	CO	Colorado		213	Coxsackievirus A13		CODE	SPECIMENTYPE
6	6		CODE	ABBR	SEX		9	CT	Connecticut		214	Coxsackievirus A14		1	CSF
7	7		1	F	Female		10	DE	Delaware		215	Coxsackievirus A15		6	Lesion swab/scraping
8	8		0	M	Male		11	DC	District of Columbia		216	Coxsackievirus A16		5	Other (specify)
9	9		9	U	Unknown		12	FL	Florida		217	Coxsackievirus A17		7	Plasma
10	10						13	GA	Georgia		218	Coxsackievirus A18		8	Serum
11	11		ILLNESS OUTCOME				15	HI	Hawaii		219	Coxsackievirus A19		2	Stool/Rectal Swab
12	12		CODE	IllnessOutcome			16	ID	Idaho		202	Coxsackievirus A2		3	Throat/NP Swab
13	13		1	Living			17	IL	Illinois		220	Coxsackievirus A20		10	Tissue (biopsy)
14	14		2	Deceased			18	IN	Indiana		221	Coxsackievirus A21		11	Tissue (post mortem)
15	15		9	Unknown			19	IA	Iowa		222	Coxsackievirus A22		4	Tissue Culture
16	16						20	KS	Kansas		224	Coxsackievirus A24		9	Unknown
17	17						21	KY	Kentucky		203	Coxsackievirus A3		12	Urine
18	18						22	LA	Louisiana		204	Coxsackievirus A4		13	Whole blood
19	19						23	ME	Maine		205	Coxsackievirus A5
20	20						24	MD	Maryland		206	Coxsackievirus A6
21	21						25	MA	Massachusetts		207	Coxsackievirus A7
22	22						26	MI	Michigan		208	Coxsackievirus A8
23	23						27	MN	Minnesota		209	Coxsackievirus A9
24	24						28	MS	Mississippi		399	Coxsackievirus B Type Unknown
25	25						29	MO	Missouri		301	Coxsackievirus B1
26	26						30	MT	Montana		302	Coxsackievirus B2
27	27						31	NE	Nebraska		303	Coxsackievirus B3
28	28						32	NV	Nevada		304	Coxsackievirus B4
29	29						33	NH	New Hampshire		305	Coxsackievirus B5
30	30						34	NJ	New Jersey		306	Coxsackievirus B6
31	31						35	NM	New Mexico		401	Echovirus 1
32	32						36	NY	New York		411	Echovirus 11
33	33						37	NC	North Carolina		412	Echovirus 12
34	34						38	ND	North Dakota		413	Echovirus 13
35	35						39	OH	Ohio		414	Echovirus 14
36	36						40	OK	Oklahoma		415	Echovirus 15
37	37						41	OR	Oregon		416	Echovirus 16
38	38						42	PA	Pennsylvania		417	Echovirus 17
39	39						44	RI	Rhode Island		418	Echovirus 18
40	40						45	SC	South Carolina		419	Echovirus 19
41	41						46	SD	South Dakota		402	Echovirus 2
42	42						47	TN	Tennessee		420	Echovirus 20
43	43						48	TX	Texas		421	Echovirus 21
44	44						49	UT	Utah		422	Echovirus 22
45	45						50	VT	Vermont		423	Echovirus 23
46	46						51	VA	Virginia		424	Echovirus 24
47	47						53	WA	Washington		425	Echovirus 25
48	48						54	WV	West Virginia		426	Echovirus 26
49	49						55	WI	Wisconsin		427	Echovirus 27
50	50						56	WY	Wyoming		429	Echovirus 29
51	51						60	AS	American Samoa		403	Echovirus 3
52	52						64	FM	Federated States of Micronesia		430	Echovirus 30
53	53						66	GU	Guam		431	Echovirus 31
54	54						69	MP	Northern Mariana Islands		432	Echovirus 32
55	55						70	PW	Palau		433	Echovirus 33
56	56						72	PR	Puerto Rico		224	Echovirus 34
57	57						74	UM	U.S. Minor Outlying Islands		404	Echovirus 4
58	58						78	VI	Virgin Islands		405	Echovirus 5
59	59						99	UNK	Unknown		406	Echovirus 6
60	60										407	Echovirus 7
61	61										401	Echovirus 8
62	62										409	Echovirus 9
63	63										499	Echovirus Type Unknown
64	64										501	Enterovirus 68
65	65										502	Enterovirus 69
66	66										503	Enterovirus 70
67	67										599	Enterovirus 70/71
68	68										504	Enterovirus 71
69	69										505	Enterovirus 73
70	70										999	Enterovirus Type Unknown
71	71										400	Parechovirus Type Unknown
72	72										422	Parechovirus 1
73	73										423	Parechovirus 2
74	74										434	Parechovirus 3
75	75										435	Parechovirus 4
76	76										436	Parechovirus 5
77	77										437	Parechovirus 6
78	78										601	Poliovirus 1
79	79										602	Poliovirus 2
80	80										603	Poliovirus 3
81	81										699	Poliovirus Type Unknown
82	82
83	83
84	84
85	85
86	86
87	87
88	88
89	89
90	90
91	91
92	92
93	93
94	94
95	95
96	96
97	97
98	98
99	99
100	100
101	101
102	102
103	103
104	104
105	105
106	106
107	107
108	108
109	109
999	Unknown