Novel Influenza A Virus Case Screening Form

Novel Influenza A Virus Case Screening Form
May be used by local health departments for cases under investigation (CUI) for possible human infection with novel influenza A viruses
(e.g., variant H3N2v, avian H7N9). Please refer to case definitions for novel influenza A viruses for additional guidance.
Reporting county:

Case residence county:

Case phone:

Interviewer name:

Phone:

Email:

Case name:

Parent/guardian name (for minors):

Please send the portion below to the Influenza Division at CDC (email: [email protected])
Date of report: (mm/dd/yyyy):______________

☐New report
☐Update to previous report

State Case ID #:

Person reporting: __________________
Contact phone: ____________________

Specimen Collection Date (mm/dd/yyyy):

What is the subtype?
(Required)
☐Influenza A(H1N1) variant
☐Influenza A(H1N2) variant
☐Influenza A(H3N2) variant
☐Influenza A(H5N1)

State Lab Specimen ID #1:
☐Influenza A(H7N9)
☐Unknown
☐Other _______________

At the time of this report, is the case ☐Confirmed
State of Residence:

Was the specimen submitted to CDC?
☐Yes ☐No ☐Unknown

☐Probable

☐Under Investigation

Country of usual residence:

☐Days

Age Type:

☐Weeks

☐Months

☐Not a Case

If usual resident of U.S., County of Residence:

Sex: ☐Male

Date of Birth (mm/dd/yyyy):
Age: ______

State Lab Specimen ID #2:

☐Female

☐Years

Did the patient have 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?
☐Yes ☐No ☐Unknown
Illness Onset Date (mm/dd/yyyy):
Hospitalized?
☐Yes ☐No ☐Unknown
ICU?

☐Yes

☐No

Death? ☐Yes ☐No ☐Unknown

☐Unknown

Contact of a confirmed case?

☐Yes

☐No ☐Unknown

Employed at a health care facility? ☐Yes

Any wild bird/poultry contact in 10 days prior to illness onset?
Where did this wild bird/poultry contact occur?
(select all that apply)
☐Participated in a depopulation event
☐Worked or lived on farm where HPAI was detected

Date of Death (mm/dd/yyyy):

☐Yes

☐No

☐No ☐Unknown

☐Unknown

If participated in a depopulation event or worked or lived on a
farm where HPAI was detected, indicate the outbreak ID (if
patient was being monitored due to mobilization for poultry
outbreak, enter the outbreak ID here):

☐Hunted and harvested a wild bird
☐Other, specify: _________________
Any swine contact in 7 days prior to
illness onset?
☐Yes ☐No ☐Unknown

Agricultural event/live animal market attendance in 7 days prior to illness onset?
☐Yes ☐No ☐Unknown
If Yes, specify name:

Notes/Comments:
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 Information Collection Review Office, 1600 Clifton Road NE, MS
D‐74, Atlanta, Georgia 30333; ATTN: PRA (0920‐0004).

• For CUIs, arrange for nasopharyngeal (NP) swab collection and RT-PCR testing at a state public health laboratory.
• Patients with influenza-like illness should discuss possible antiviral treatment with a healthcare provider.
• Healthcare facilities should use appropriate isolation precautions for cases under investigation for infection with novel influenza A
viruses. Non-hospitalized cases under investigation should stay home from school, work, and social gatherings until fever is gone for at
least 24 hours without the use of fever-reducing medications.
• If this case is later determined to be a confirmed case of infection with novel influenza A, please notify CDC and complete the CDC
Human Infection with Novel Influenza A Virus Case Report Form.