Human Infection with Novel Influenza A Virus Case Report

Human Infection with Novel Influenza A Virus
Case Report Form

Form Approved
OMB No. 0920-0004

State: ________ Date reported to health department: ___/___/_____ (MM/DD/YYYY) Date interview completed: ___/___/_____ (MM/DD/YYYY)
State Epi ID:_______________________________________________ State Lab ID: ________________________________________________
Household ID (CDC use only):_________CDC ID (CDC use only):______________________ Cluster ID (CDC use only):_____________________
1. At the time of this report, is the case
Confirmed
Probable
Case under investigation (skip to Q.3)
Not a case (skip to Q.3)
2. What is the subtype? (If a variant subtype is selected, please complete the Human Infection with Novel Influenza A Variant Module. If an avian
subtype is selected, please complete the Human Infection with Novel Influenza A Virus Avian Module).
Influenza A(H1N1) variant
Influenza A(H1N2) variant
Influenza A(H3N2) variant
Influenza A(H5N1) avian
Influenza A(H7N9) avian
Other _____________________________________________________________________
Unknown

Demographic Information
3.
4.
5.
6.
7.
8.

Date of birth: _____/_____/_____ (MM/DD/YYYY)
Country of usual residence: ____________________________ If usual resident of U.S., county of residence: ____________________________
White
Asian
American Indian/Alaska Native
Black
Native Hawaiian/Other Pacific Islander
Race: (check
all that apply)
Hispanic or Latino
Not Hispanic or Latino
Ethnicity:
Male
Female
Sex:
Occupation

Symptoms, Clinical Course, Treatment, Testing, and Outcome
9. What date did symptoms associated with this illness start? _____/_____/_______ (MM/DD/YYYY)
10. During this illness, did the patient experience any of the following?
Symptom
Symptom Present?
Symptom
Symptom Present?
Fever (highest temp _________ oF)
Yes
No
Unk Shortness of breath
Yes
No
Unk
If fever present, date of onset ___/___/____ (MM/DD/YYYY)
Vomiting
Yes
No
Unk
Felt feverish
Yes
No
Unk Diarrhea
Yes
No
Unk
If felt feverish, date of onset ___/___/____ (MM/DD/YYYY)
Eye infection/redness
Yes
No
Unk
Cough
Yes
No
Unk Rash
Yes
No
Unk
Sore Throat
Yes
No
Unk Fatigue
Yes
No
Unk
Muscle aches
Yes
No
Unk Seizures
Yes
No
Unk
Headache
Yes
No
Unk Other, specify
Yes
No
Unk
11. Does the patient still have symptoms?
Yes (skip to Q.13)
No
Unknown (skip to Q.13)
12. When did the patient feel back to normal? _____/_____/_____ (MM/DD/YYYY)
13. Did the patient receive any medical care for the illness?
Yes
No (skip to Q.30)
Unknown (skip to Q.30)
14. Where and on what date did the patient seek care (check all that apply)?
Doctor’s office date:_____/_____/_____ (MM/DD/YYYY)
Emergency room date:_____/_____/_____ (MM/DD/YYYY)
Urgent care clinic date:_____/_____/_____ (MM/DD/YYYY)
Health department date:_____/_____/_____ (MM/DD/YYYY)
Other _______________________________ date:_____/_____/_____ (MM/DD/YYYY)
Unknown
15. Was the patient hospitalized for the illness?
Yes
No (skip to Q.24)
Unknown (skip to Q.24)
16. Date(s) of hospital admission? First admission date:___/___/____ (MM/DD/YYYY) Second admission date:___/___/____ (MM/DD/YYYY)
17. Was the patient admitted to an intensive care unit (ICU)?
Yes
No (skip to Q.19)
Unknown (skip to Q.19)
18. Date of ICU admission: ______/_____/_______ (MM/DD/YYYY) Date of ICU discharge: ______/_____/_______ (MM/DD/YYYY)
19. Did the patient receive mechanical ventilation / have a breathing tube?
Yes
No (skip to Q.21)
Unknown (skip to Q.21)
20. For how many days did the patient receive mechanical ventilation or have a breathing tube? ___________________ days
21. Was the patient discharged?
Yes
No (skip to Q.24)
Unknown (skip to Q.24)
22. Date(s) of hospital discharge? First discharge date:___/___/____ (MM/DD/YYYY) Second discharge date:___/___/____ (MM/DD/YYYY)
23. Where was the patient discharged?
Home
Nursing facility/rehab
Hospice
Other _________________________
Unknown
Public reporting burden of this collection of information is estimated to average 30 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).

Human Infection with Novel Influenza A Virus
Case Report Form
24. Did the patient have a new abnormality on chest x-ray or CAT scan?
No, x-ray or scan was normal
Yes, x-ray or scan detected new abnormality
No, chest x-ray or CAT scan not performed
Unknown
25. Did the patient receive a diagnosis of pneumonia?
Yes
No
Unknown
26. Did the patient receive a diagnosis of ARDS?
Yes
No
Unknown
27. Did the patient have leukopenia (white blood cell count <5000 leukocytes/mm3) associated with this illness?
Normal
Abnormal
Test not performed
Unknown
28. Did the patient have lymphopenia (total lymphocytes <800/mm3 or lymphocytes <15% of WBC) associated with this illness?
Normal
Abnormal
Test not performed
Unknown
29. Did the patient have thrombocytopenia (total platelets <150,000/mm3) associated with this illness?
Normal
Abnormal
Test not performed
Unknown
30. Did the patient experience any other complications as a result of this illness?
Yes (please describe below)
No
Unknown
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
31. Did the patient receive influenza antiviral medications prior to becoming ill (within 2 weeks) or after becoming ill?
Yes, (please complete table below)
No
Unknown
Start date
End date
Total number of days
Drug
(MM/DD/YYYY) (MM/DD/YYYY)
receiving antivirals
Oseltamivir (Tamiflu)
Zanamivir (Relenza)
Peramivir (Rapivab)
Other influenza antiviral_____________________
32. Did the patient die as a result of this illness?
Yes, Date of death:_____/_____/_____ (MM/DD/YYYY)
No
Unknown

Dosage
(if known)
mg
mg
mg
mg

Influenza Testing
33. When was the specimen collected that indicated novel influenza A virus infection by Reverse Transcription-Polymerase Chain Reaction (RTPCR)? ______/______/_______ (MM/DD/YYYY)
Doctor’s office
Hospital
Emergency room
Urgent care clinic
Health department
34. Where was the specimen collected?
Other ____________________________________________
Unknown
35. Was a rapid influenza diagnostic test (RIDT) used on any respiratory specimens collected?
Yes
No (skip to Q.39)
Unknown (skip to Q.39)
36. When was the RIDT specimen collected? ______/______/_______ (MM/DD/YYYY)
Influenza A
Influenza B
Influenza A/B (type not distinguished)
Negative
Other _______________
37. What was the result?
38. What brand of RIDT was used? _____________________________________________________________

Medical History -- Past Medical History and Vaccination Status
39. Does the patient have any of the following chronic medical conditions? Please specify ALL conditions that qualify.
a.

Asthma/reactive airway disease

Yes

No

Unknown

b.

Other chronic lung disease

Yes

No

Unknown (If YES, specify) _______________________________

c.

Chronic heart or circulatory disease

Yes

No

Unknown (If YES, specify) _______________________________

d.

Diabetes mellitus

Yes

No

Unknown (If YES, specify) _______________________________

e.

Kidney or renal disease

Yes

No

Unknown (If YES, specify) _______________________________

f.

Non-cancer immunosuppressive condition

Yes

No

Unknown (If YES, specify) _______________________________

g.

Cancer chemotherapy in past 12 months

Yes

No

Unknown (If YES, specify) _______________________________

h.

Neurologic/neurodevelopmental disorder

Yes

No

Unknown (If YES, specify) _______________________________

i. Other chronic diseases
Yes
No
Unknown (If YES, specify) _______________________________
40. Does the patient frequently use a stroller or wheelchair? If yes, please describe.
Yes
No
Unknown
41. Was patient pregnant or ≤6 weeks postpartum at illness onset?
Yes, pregnant (weeks pregnant at onset)________
Yes, postpartum (delivery date) ___/___/____ (MM/DD/YYYY)
No
Unknown
42. Does the patient currently smoke?
Yes
No
Unknown

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Human Infection with Novel Influenza A Virus
Case Report Form
43. Was the patient vaccinated against influenza in the past year?
Yes
No (skip to Q.46)
Unknown (skip to Q.46)
44. Month and year of influenza vaccination? Vaccination date 1:____/_____ (MM/YYYY) Vaccination date 2:____/_____ (MM/YYYY)
Inactivated (injection)
Live attenuated (nasal spray)
Unknown
45. Type of influenza vaccine (check all that apply):

Epidemiologic Risk Factors
46. In the 10 days prior to illness onset, did the patient travel outside of his/her usual area?
Yes
No (skip to Q.50)
Unknown (skip to
Q.50)
47. When and where did the patient travel? Please describe details of the patient’s travel in the notes section at the end of the form.
Trip 1: Dates of travel: _____/_____/_____ to _____/_____/_____ Country ______________ State _______ City/County________________
Trip 2: Dates of travel: _____/_____/_____ to _____/_____/_____ Country ______________ State _______ City/County________________
48. Did the patient travel in a group (check all that apply)?
No, travelled alone
Yes, with household members
Yes, with non-household members
Unknown
49. Please describe the details of the trip ______________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
50. In the 10 days prior to illness onset, did the patient attend a public event where a large number of people were present (e.g., a sporting event,
Yes
No (skip to Q.52)
Unknown (skip to Q.52)
wedding, concert)?
51. Please describe the event (include date and location)
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
52. In the 10 days prior to illness onset, or at any time after illness onset, did the patient travel by means of public conveyance where others were
present (e.g., public bus or train)?
Yes
No (skip to Q.54)
Unknown (skip to Q.54)
53. Please describe means and frequency of public travel
54. In the 10 days prior to illness onset, did the patient have close contact with someone who travelled outside the United States?
Yes
No (skip to Q.56)
Unknown (skip to Q.56)
55. Please describe individual (including travel location)

Risk Factors—Animal Exposure
56. In the 10 days before becoming ill, did the patient attend an agricultural fair/event?
Yes (specify name, if >1 fair, please describe in the notes section __________________)
No
Unknown
57. In the 10 days before becoming ill, did the patient attend a live animal market?
Yes (specify name, if >1 market, please describe in the notes section __________________)
No
Unknown (If the answers to Q.56
and Q.57 are both No or Unknown skip to Q.59.)
58. In the 10 days before becoming ill, on what days did the patient attend an agricultural fair/event or live animal market (check all that apply)?
on the day of illness onset
1 day before illness onset
2 days before illness onset
3 days before illness onset
4 days before illness onset
5 days before illness onset
6 days before illness onset
7 days before illness onset
8 days before illness onset
9 days before illness onset
10 days before illness onset
59. In the 10 days before becoming ill, did the patient have DIRECT contact with (e.g., touch or handle) any animals?
Yes
No (skip to Q.62)
Unknown (skip to Q.62)
60. What type(s) of animals did the patient have direct contact with (check all that apply)?
Horses
Cows
Poultry/wild birds
Sheep
Goats
Pigs/hogs
Other (1)__________________________
Other (2)__________________________
Other (3)__________________________
Other (4)__________________________
61. Where did the direct contact occur (check all that apply)?
Home
Work
Agricultural fair or event
Live animal market
Petting zoo
Other____________________________
62. In the 10 days before becoming ill, did the patient have CLOSE contact with (e.g., walk through an area containing or come within about 6 feet
of) any animals?
Yes
No (skip to Q.65)
Unknown (skip to Q.65)
63. What type(s) of animals did the patient have close contact with (check all that apply)?
Horses
Cows
Poultry/wild birds
Sheep
Goats
Pigs/hogs
Other (1)__________________________
Other (2)__________________________
Other (3)__________________________
Other (4)__________________________
64. Where did the close contact occur (check all that apply)?
Home
Work
Agricultural fair or event
Live animal market
Petting zoo
Other____________________________

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Human Infection with Novel Influenza A Virus
Case Report Form
65. In the 10 days before becoming ill, did the patient have direct or close contact with any animal exhibiting signs of illness?
Yes (specify animal type and location __________________________________________________)
No
Unknown
66. Does anyone in the household own, keep or care for livestock animals (either at home or in the workplace)?
Yes
No (skip to Q.68)
Unknown (skip to Q.68)
67. What type(s) of animals are kept or cared for by household members (check all that apply)?
Horses
Cows
Poultry/wild birds
Sheep
Goats
Pigs/hogs
Other (1)__________________________
Other (2)__________________________
Other (3)__________________________
Other (4)__________________________
Risk Factors—Household, Occupational, Nosocomial, and Secondary Spread
68. Does the patient reside in an institutional or group setting (e.g. nursing home, boarding school, college dormitory)?
Yes (skip to Q.70)
No
Unknown (skip to Q.70)
69. How many people resided in the patient’s household(s) in the week before or after illness onset (excluding the patient)? ________
A household member is anyone with at least one overnight stay +/- 7 days from patient’s illness onset, and the patient may have resided
in >1 household. Please complete the table below for each household member and continue in the notes section if more space is needed.

ID

1
2
3
4
5
6

Household (HH)
[“A” should be the
patient’s primary
household]
A
A
A
A
A
A

B
B
B
B
B
B

C
C
C
C
C
C

Relation to patient (e.g. parent,
brother, friend)

Sex
(M/F)

Age

Was HH member ill (fever
or any respiratory symptom)
+/– 7 days from case
patient’s onset?
Y
Y
Y
Y
Y
Y

N
N
N
N
N
N

If Yes, HH member’s
date of
illness onset

U
U
U
U
U
U

70. In the 7 days before or after becoming ill, did the patient attend or work at a child care facility?
Yes (before becoming ill)
Yes (after becoming ill)
No (skip to Q.72)
Unknown (skip to Q.72)
71. Approximately how many children are in the patient’s class or room at the child care facility? ______________
72. In the 7 days before or after becoming ill, did the patient attend or work at a school?
Yes (before becoming ill)
Yes (after becoming ill)
No (skip to Q.74)
Unknown (skip to Q.74)
73. Approximately how many students are in the patient’s class at the school? ______________ children
74. In the 7 days before or after the patient became ill, did anyone else in the patient’s household(s) work at or attend a child care facility or school?
Yes
No (skip to Q.76)
Unknown (skip to Q.76)
75. List ID numbers from Q.69 (the table above) for household members working at or attending a child care facility or school:
_________________________________________________________________________________________________________________
76. Does the patient handle samples (animal or human) suspected of containing influenza virus in a laboratory or other setting?
Yes
No
Unknown
77. In the 7 days before or after becoming ill, did the patient work in or volunteer at a healthcare facility or setting?
Yes
No (skip to Q.80)
Unknown (skip to Q.80)
78. Specify healthcare facility job/role:
Physician
Nurse
Administration staff
Housekeeping
Patient transport
Volunteer
Other_________________________
79. Did the patient have direct patient contact while working or volunteering at a healthcare facility?
Yes
No
Unknown
80. In the 7 days before becoming ill, was the patient in a hospital for any reason (i.e., visiting, working, or for treatment)?
Yes
No
Unknown
If yes, what were the dates? ____/____/_____, ____/____/_____
City/Town ______________________________________
81. In the 7 days before becoming ill, was the patient in a clinic or a doctor’s office for any reason?
Yes
No
Unknown
If yes, what were the dates? ____/____/_____, ____/____/_____
City/Town ______________________________________
82. Does the patient know anyone other than a household member who had fever, respiratory symptoms like cough or sore throat, or another
respiratory illness like pneumonia in the 7 days BEFORE the case patient’s illness onset?
Yes (please list those ill before the case patient in the table below)
No
Unknown

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Human Infection with Novel Influenza A Virus
Case Report Form
ID

Relationship to patient

Sex
(M/F)

Age

Date of
illness onset

Comments

1
2
3
4
83. Does the patient know anyone other than a household member who had fever, respiratory symptoms like cough or sore throat, or another
respiratory illness like pneumonia beginning AFTER the case patient’s illness onset?
Yes (please list those ill after the case patient in the table below)
No
Unknown
ID
Sex
Date of
Relationship to patient
Age
Comments
(M/F)
illness onset
1
2
3
4
84. Is the patient a contact of a confirmed or probable case of novel influenza A infection?
Yes (please list patient’s confirmed or probable contacts in the table below)
No
Unknown
Date of illness
Sex
Relationship to patient
State Epi ID
State Lab ID
Case status
Age
onset
(M/F)
(MM/DD/YYYY)
Confirmed
Probable
Confirmed
Probable
Confirmed
Probable
Confirmed
Probable
85. Any additional comments or notes (e.g. travel details, names/dates of fairs or live markets attended by case patient, dates of household members
fair attendance and location of fair, information about other ill contacts)?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

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Human Infection with Novel Influenza A Virus
Case Report Form
Variant Module – complete only if confirmed case with a variant influenza virus (i.e. H1N1v, H1N2v, H3N2v)
86. In the 10 days before becoming ill, on what days did the patient have ANY exposure (touch or handle pigs or touch potentially contaminated
surfaces or walk through an area containing or come within 6 feet of any pigs/hogs) with pigs (check all that apply)?
on the day of illness onset
1 day before illness onset
2 days before illness onset
3 days before illness onset
4 days before illness onset
5 days before illness onset
6 days before illness onset
7 days before illness onset
8 days before illness onset
9 days before illness onset
10 days before illness onset
87. What was the total number of different days the patient reported ANY pig exposure (direct or any other exposure or both)? ____________ days.
88. Please describe animal exposure for all household members listed in Q.62 of the main Novel A Case Report Form (please use the same id for
each person as in Q. 69 of the main form).
If HH member was ILL
ID

1
2
3
4
5
6

Did HH member have any pig/hog
exposure ≤10 days before his/her
onset?
Y
Y
Y
Y
Y
Y

N
N
N
N
N
N

U
U
U
U
U
U

If HH member was NOT ILL

Did HH member visit a live
market or fair ≤10 days before
his/her onset?
Y
Y
Y
Y
Y
Y

N
N
N
N
N
N

U
U
U
U
U
U

Did HH member have any pig/hog
exposure or visit a live market visit ≤10
days before the case-patient’s illness
onset?
Y
N
U
Y
N
U
Y
N
U
Y
N
U
Y
N
U
Y
N
U

89. In the 7 days before becoming ill, did the patient have direct or any other exposure (e.g. caring for, speaking with, or touching) with anyone
other than a household member who routinely has exposure with pigs/hogs?
Yes
No
Unknown
90. Please describe the pig/hog exposure and fair attendance for individuals listed in Q. 82 of the main Novel A Case Report Form.
Any pig/hog exposure or fair
ID
attendance ≤10 days before his/her
Comments
onset?
1
Y
N
U
2
Y
N
U
3
Y
N
U
4
Y
N
U
91. Please describe the pig/hog exposure and fair attendance of individuals listed in Q. 83 of the main Novel A Case Report Form.
Any pig/hog exposure or fair
ID
attendance ≤10 days before his/her
Comments
onset?
1
Y
N
U
2
3
4

Y
Y
Y

N
N
N

U
U
U

92. Notes

______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________

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Human Infection with Novel Influenza A Virus
Case Report Form
Avian Module – complete only if confirmed case with an avian influenza virus (i.e. H5N1, H7N9)
1.
2.

3.

4.

5.

6.

7.

8.
9.
10.

11.
12.

13.

14.

15.
16.
17.

Has the patient ever received an influenza H5N1 vaccination?
Yes (Date: ___/___/______
No
Unknown
In the 10 days before becoming ill, did the patient have DIRECT contact (touch or handle) with poultry (chickens, turkeys, ducks, or geese,
etc.)?
Yes
No (skip to Q.5)
Unknown (skip to Q.5)
Where did the DIRECT contact with poultry occur (check all that apply)?
Home
Commercial poultry farm
Agricultural fair or event
Live animal market
Petting zoo
Veterinary care
Slaughterhouse Other____________________________
What type(s) of poultry did the patient have DIRECT contact with (check all that apply)?
Chickens
Turkeys
Geese
Pheasants
Ducks
Ostriches
Emus
Pigeons
Other____________________________
In the 10 days before becoming ill, did the patient have any other exposure to (e.g., touch potentially contaminated surfaces, walk through an
area containing or come within 6 feet of) poultry?
Yes
No (skip to Q.8)
Unknown (skip to Q.8)
Where did this exposure to poultry occur (check all that apply)?
Home
Commercial poultry farm
Agricultural fair or event
Live animal market
Petting zoo
Veterinary care
Slaughterhouse Other____________________________
What type(s) of poultry did the patient have this exposure to (check all that apply)?
Chickens
Turkeys
Geese
Pheasants
Ducks
Ostriches
Emus
Pigeons
Other____________________________
Did the patient clean any poultry pens/houses in the 10 days before becoming ill?
Yes
No
Unknown
Did the patient feed or water any poultry in the 10 days before becoming ill?
Yes
No
Unknown
Did the patient have direct contact with surfaces contaminated by bird or poultry feces or poultry parts (carcasses, internal organs, etc.) in the 10
days before becoming ill?
Yes
No
Unknown
Did the patient participate in the culling of any poultry flocks?
Yes
No (skip to Q.14)
Unknown (skip to Q.14)
What measures did the patient use to protect himself/herself during the culling (check all that apply)?
None
Facemask
Respirators
Hand gloves
Eyeglasses
Gowns
Boots
Unknown
Other____________________________
What percentage of time did the person participating in culling wear the items mentioned above while culling flocks (only ask about the items
the exposed person mention in Q. 12)?
___% Facemask
___% Respirators
___% Hand gloves
___% Eye protection
___% Gowns
___% Boots
___% Other____________________________
In the 10 days before becoming ill, on what days did the patient have ANY exposure (direct or any other exposure or both) with birds or poultry
(check all that apply)?
on the day of illness onset
1 day before illness onset
2 days before illness onset
3 days before illness onset
4 days before illness onset
5 days before illness onset
6 days before illness onset
7 days before illness onset
8 days before illness onset
9 days before illness onset
10 days before illness onset
From Q.14, what was the total number of different days the patient reported ANY bird or poultry exposure (direct, or any other exposure or
both)? ___________ days
Did the patient report ANY exposure (direct or any other exposure or both) with any ill-appearing poultry in the 10 days before becoming ill?
Yes, specify_________________________________________
No
Unknown
Did the patient report ANY exposure (direct, or any other exposure, or both) with dead poultry in the 10 days before becoming ill?
Yes, specify_________________________________________
No
Unknown

Risk Factors—Household bird and poultry practices
18. Were poultry raised on the patient’s property?
Yes
No (skip to Q.26)
Unknown (skip to Q.26)
19. Where were the poultry kept (check all that apply)?
In patient’s basement or garage
Inside patient’s house/living space
Open-air poultry pen or poultry house
Enclosed poultry pen or poultry house
Other enclosure/cage outside the patient’s house
Other____________________________

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Human Infection with Novel Influenza A Virus
Case Report Form
20. What type(s) of poultry did the patient raise (check all that apply)? Please estimate the number of each type raised.
Chickens ____#
Turkeys ____#
Geese ____#
Pheasants ____#
Ducks ____#
Ostriches ____#
Emus ____#
Pigeons ____#
Other____________________________ ____#
21. Did the patient’s household have any recent (within the past 30 days) ill-appearing poultry?
Yes
No
Unknown
22. Did the patient’s household have any recent poultry die-offs?
Yes
No (skip to Q.26)
Unknown (skip to Q.26)
23. Please indicate the percent of the flock that died. ________________%
24. When did the die-off begin and end? Begin date: ____/____/____ (MM/DD/YYYY)
End date: ____/____/____ (MM/DD/YYYY)
25. Was the flock culled?
Yes (date ____/____/____ MM/DD/YY)
No
Unknown
26. Did the patient have exposure to any eggs from a private flock (i.e., not store bought or commercial) in the 10 days before becoming ill?
Yes
No
Unknown
27. Did the patient consume raw or undercooked poultry in the 10 days before becoming ill?
Yes
No
Unknown
28. Does anyone else in the household own, keep or care for poultry in a location other than the patient’s property?
Yes, specify_________________________________________
No
Unknown
29. Were there any recent reports of sick or dead poultry in the case patient’s area?
Yes, specify _________________________________________
No
Unknown
Risk Factors—Wild/Migratory and other birds
30. Were captive wild birds kept at the patient’s residence?
Yes (describe)
No
Unknown
31. Did the patient visit any areas where wild/migratory birds (e.g. herons, gulls, falcons, wild ducks, geese, or swans) are present?
Yes, specify location _________________________________________
No
Unknown
32. In the 10 days before illness onset, did the patient have ANY exposure to wild/migratory birds?
Yes
No (skip to Q.38)
Unknown (skip to Q.38)
33. In the 10 days before illness onset, did the patient have any DIRECT contact (touch or handle) with any wild/migratory birds?
Yes, specify type of bird(s) _________________________________________
No
Unknown
34. In the 10 days before becoming ill, did the patient have any other exposure to (walk through an area containing or come within 6 feet of) any
wild/migratory birds?
Yes, specify type of bird(s) _________________________________________
No
Unknown
35. Were any of the wild/migratory birds that the patient had ANY contact with sick or dying?
Yes, specify___________________________________________________
No
Unknown
36. In the 10 days before becoming ill, on what days did the patient have ANY exposure (direct or any other exposure or both) with wild birds
(check all that apply)?
on the day of illness onset
1 day before illness onset
2 days before illness onset
3 days before illness onset
4 days before illness onset
5 days before illness onset
6 days before illness onset
7 days before illness onset
8 days before illness onset
9 days before illness onset
10 days before illness onset
37. In the 10 days before becoming ill, did the patient have ANY exposure (direct or any other exposure or both) with birds other than poultry or
wild/migratory birds?
Yes, specify type of bird(s) _________________________________________
No (skip to Q.41)
Unknown (skip to Q.41)
38. Were any of these birds that the patient had ANY exposure (direct or any other exposure or both) with sick or dying?
Yes, specify___________________________________________________
No
Unknown
39. In the 10 days before becoming ill, on what days did the patient have ANY exposure (direct or any other exposure or both) with these birds
(check all that apply)?
on the day of illness onset
1 day before illness onset
2 days before illness onset
3 days before illness onset
4 days before illness onset
5 days before illness onset
6 days before illness onset
7 days before illness onset
8 days before illness onset
9 days before illness onset
10 days before illness onset
Risk Factors—Human exposures
40. Please describe bird/poultry exposure for all household members listed in Q.69 of the main Novel A Case Report Form (please use the same
ID as in Q.62).
ID

If HH member was ILL

If HH member was NOT ILL

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Human Infection with Novel Influenza A Virus
Case Report Form

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2
3
4
5
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Did HH member have any bird
exposure ≤10 days before his/her
onset?
Y
N
U
Y
N
U
Y
N
U
Y
N
U
Y
N
U
Y
N
U

Did HH member visit a live
market ≤10 days before his/her
onset?
Y
N
U
Y
N
U
Y
N
U
Y
N
U
Y
N
U
Y
N
U

Did HH member have any bird exposure
or visit a live market visit ≤10 days before
the case-patient’s illness onset?
Y
N
U
Y
N
U
Y
N
U
Y
N
U
Y
N
U
Y
N
U

41. Please describe the bird exposure and live market visits for individuals listed in Q.82 of the main Novel A Case Report Form.
Any bird exposure or live market
ID
Comments
visits ≤10 days before his/her onset?
1
Y
N
U
2
Y
N
U
3
Y
N
U
4
Y
N
U
42. Please describe the bird exposure and live market visits of individuals listed in Q.83 of the main Novel A Case Report Form.
Any bird exposure or live market
ID
Comments
visits ≤10 days before his/her onset?
1
Y
N
U
2
Y
N
U
3
Y
N
U
4
Y
N
U
43. In the 7 days before becoming ill, did the patient have direct or other exposure (e.g., caring for, speaking with, or touching) with anyone other
than a household member who routinely has exposure to birds?
Yes
No
Unknown
44. Notes

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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