0920-0004 Human Infection with Novel Influenza A Virus Case Report

Form Approved

Human Infection with Novel Influenza A Virus

Case Report Form

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

Demographic Information

Influenza A(H7N9) avian Other Unknown

3. Date of birth: / / (MM/DD/YYYY)

4. Country of usual residence: If usual resident of U.S., county of residence:

5. Race: (check all that apply) White Asian American Indian/Alaska Native Black

Native Hawaiian/Other Pacific Islander

6. Ethnicity: Hispanic or Latino Not Hispanic or Latino

7. Sex: Male Female

8. 
   

   Symptoms, Clinical Course, Treatment, Testing, and Outcome

   Occupation

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).

24. Did the patient have a new abnormality on chest x-ray or CT scan?

No, x-ray or scan was normal Yes, x-ray or scan detected new abnormality No, chest x-ray or CT 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

    Drug	Start date (MM/DD/YYYY)	End date (MM/DD/YYYY)	Total number of days receiving antivirals	Dosage (if known)
    Oseltamivir (Tamiflu)				mg
    Zanamivir (Relenza)				mg
    Peramivir (Rapivab)				mg
    Other influenza antiviral				mg

32. Did the patient die as a result of this illness?

Influenza Testing

Yes, Date of death: / / (MM/DD/YYYY) No Unknown

33. When was the specimen collected that indicated novel influenza A virus infection tested by Reverse Transcription-Polymerase Chain Reaction (RT-

PCR)? / / (MM/DD/YYYY)

34. Where was the specimen collected? Doctor’s office Hospital Emergency room Urgent care clinic Health department

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)

37. What was the result? Influenza A Influenza B Influenza A/B (type not distinguished) Negative Other

38. 
    

    Medical History -- Past Medical History and Vaccination Status

    What brand of RIDT was used?

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

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)

45. 
    

    Epidemiologic Risk Factors

    Type of influenza vaccine (check all that apply): Inactivated (injection) Live attenuated (nasal spray) Other _______________ Unknown

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, wedding, concert)? Yes No (skip to Q.52) Unknown (skip to Q.52)

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 and Animal Product Exposure

56. In the 10 days before becoming ill, did the patient attend an agricultural fair or event (e.g. show or auction)?

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 any animals? Direct contact is defined as: handling, touching, or petting an animal. This could have been at your home or another home, at a pet store, petting zoo, retail store, school, daycare, or other location.

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 Slaughterhouse/rendering facility

Other

62. In the 10 days before becoming ill, did the patient have any other exposure to (touch potentially contaminated surfaces, walk through an area containing or come within 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 this exposure to from Q.62 (e.g, touch potentially contaminated surfaces, walk through an area containing or come within 6 feet of ) (check all that apply)?

Horses Cows Poultry/wild birds Sheep Goats Pigs/hogs Other (1)

Other (2)

Other (3)

Other (4)

64. Where did this exposure occur (check all that apply)?

Home Work Agricultural fair or event Live animal market Petting zoo Other

65. In the 10 days before becoming ill, did the patient have direct or any other contact with any animal exhibiting signs of illness?

Yes (specify animal type and location ) No Unknown

66. In the 10 days before becoming ill, did the patient have direct or any other contact with any animal confirmed to be influenza A positive?

Yes (specify animal type and location ) No Unknown

Yes (specify influenza subtype (if known) ) No Unknown

67. Does anyone in the household own, keep or care for livestock, poultry, or farm animals (either at home or in the workplace)?

Yes No (skip to Q.69) Unknown (skip to Q.69)

68. What type(s) of animals are owned, 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)

69. In the 10 days before becoming ill, did the patient drink any raw or unpasteurized milk from a cow or other animal sources, including drinking milk on the farm where it was produced or drinking milk from the “bulk tank”?

Yes No Unknown Refused

(If yes ask sub-questions a through g, write in “Refused” if refused to answer or “NA” if question not applicable)

1. What type of milk (cow milk, goat milk, etc.), variety, and brand: ___________________________________ Unknown

2. What was the first date of consumption in the 10 days before becoming ill (MM-DD-YYY): ______________ Unknown

3. Where was the milk acquired (store name, farm name, herd share, etc.): __________________________ Unknown

4. What was the address, city, and state of acquisition (if not case’s home):________________________________________ Unknown

5. What was the product expiration/best by/best before date: __________________________________________ Unknown

6. What was the product lot number or code on the packaging:________________________________________ Unknown

   

7. Is there any remaining product? Yes No Unknown

1. In the 10 days before becoming ill, did the patient consume any raw or unpasteurized milk products? (select all that apply):

Raw milk cheese Heavy raw cream Whole raw kefir Raw butter Raw yogurt Raw kefir pet food Raw milk pet food Other (specify):

Unknown Refused

(If yes ask sub-questions a through g, write in “Refused” if refused to answer or “NA” if question not applicable)

1. What was the type (cow milk, goat milk, etc.), variety, and brand: _____________________________________ Unknown

2. What was the consumption date (MM-DD-YYY): Unknown

3. Where was the milk product acquired (store name, farm name, herd share, etc.): __________________________ Unknown

4. What was the address, city, and state of acquisition (if not case’s home):_________________________________________ Unknown

5. What was the product expiration/best by/best before date: ____________________________________________ Unknown

6. What was the product lot number or code on the packaging:__________________________________________ Unknown

   

7. Is there any remaining product? Yes No Unknown

Risk Factors – Household, Occupational, Nosocomial, and Secondary Spread

71. Does the patient reside in an institutional or group setting (e.g. nursing home, boarding school, college dormitory)? Yes (skip to Q.73) No Unknown (skip to Q.73)

72. 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. The patient may have resided in >1 household during this time. Please complete the table below for each household member and continue in the notes section if more space is needed.

ID	Household (HH) [“A” should be the patient’s primary household]	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?	If Yes, HH member’s date of illness onset
1	A B C				Y N U
2	A B C				Y N U
3	A B C				Y N U
4	A B C				Y N U
5	A B C				Y N U
6	A B C				Y N U

73. In the 7 days before or after becoming ill, did the patient attend or work at a childcare facility?

Yes (before becoming ill) Yes (after becoming ill) No (skip to Q.75) Unknown (skip to Q.75)

74. Approximately how many children are in the patient’s class or room at the childcare facility?

75. 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.77) Unknown (skip to Q.77)

76. Approximately how many students are in the patient’s class at the school?

77. 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 childcare facility or school? Yes No (skip to Q.79) Unknown (skip to Q.79)

78. List ID numbers from Q.72 (the table above) for household members working at or attending a childcare facility or school:

79. Does the patient handle samples (animal or human) suspected of containing influenza virus in a laboratory or other setting? Yes No Unknown

80. 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.83) Unknown (skip to Q.83)

81. Specify healthcare facility job/role:

Physician Nurse Administration staff Housekeeping Patient transport Volunteer Other

82. Did the patient have direct patient contact while working or volunteering at a healthcare facility? Yes No Unknown

83. 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

84. 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

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?

ID	Relationship to patient	Sex (M/F)	Age	Date of illness onset	Comments
1
2
3
4

Yes (please list those ill before the case patient in the table below) No Unknown

85. 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	Relationship to patient	Sex (M/F)	Age	Date of illness onset	Comments
1
2
3
4

86. 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

Relationship to patient	State Epi ID	State Lab ID	Case status		Sex (M/F)	Age	Date of illness onset (MM/DD/YYYY)
			Confirmed	Probable
			Confirmed	Probable
			Confirmed	Probable
			Confirmed	Probable

87. 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)?

Variant Module – complete only if confirmed case with a variant influenza virus (i.e. H1N1v, H1N2v, H3N2v)

88. In the 10 days before becoming ill, on what days did the patient have direct or any other exposure (touch or handle pigs or touch potentially contaminated surfaces, walk through an area containing, or come within 6 feet of any pigs/hogs) to 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

89. What was the total number of days the patient reported direct or any other pig exposure ? days.

90. Please describe animal exposure for all household members listed in Q.72 of the main Novel A Case Report Form (please use the same id for each person as in Q. 72 of the main form).

ID	If household (HH) member was ILL						If HH member was NOT ILL
	Did HH member have any pig/hog exposure ≤10 days before illness onset?			Did HH member visit a live market or fair ≤10 days before illness onset?			Did HH member have any pig/hog exposure or visit a live market visit ≤10 days before the case-patient’s illness onset?
1	Y	N	U	Y	N	U	Y	N	U
2	Y	N	U	Y	N	U	Y	N	U
3	Y	N	U	Y	N	U	Y	N	U
4	Y	N	U	Y	N	U	Y	N	U
5	Y	N	U	Y	N	U	Y	N	U
6	Y	N	U	Y	N	U	Y	N	U

91. In the 10 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

92. Please describe the pig/hog exposure and fair attendance for individuals listed in Q. 85 of the main Novel A Case Report Form.

ID	Any pig/hog exposure or fair attendance ≤10 days before his/her onset?			Comments
1	Y	N	U
2	Y	N	U
3	Y	N	U
4	Y	N	U

93. Please describe the pig/hog exposure and fair attendance of individuals listed in Q. 86 of the main Novel A Case Report Form.

ID	Any pig/hog exposure or fair attendance ≤10 days before his/her onset?			Comments
1	Y	N	U
2	Y	N	U
3	Y	N	U
4	Y	N	U

94. Notes:

Avian Module – complete only if confirmed case with an avian influenza virus (i.e. H5N1, H7N9)

95. Has the patient ever received an influenza H5N1 vaccination?

Yes (Date: / / ) No Unknown

96. In the 10 days before becoming ill, did the patient have direct contact with poultry (chickens, turkeys, ducks, or geese, etc.)? Direct contact is defined as: handling, touching, or petting an animal. This could have been at the patient's home or another home, at a pet store, petting zoo, retail store, school, daycare, or other location.

Yes No (skip to Q.100) Unknown (skip to Q.100)

97. 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/Rendering facility Other

98. What type(s) of poultry did the patient have direct contact with (check all that apply)?

Chickens Turkeys Geese Pheasants Ducks Ostriches Emu Pigeons Other

99. In the 10 days before becoming ill, did the patient have any other exposure (e.g., touch potentially contaminated surfaces, walk through an area containing or come within 6 feet of) to poultry?

Yes No (skip to Q.113) Unknown (skip to Q.113)

100. Where did this exposure from Q.100 to poultry occur (check all that apply)?

Home Commercial poultry farm Agricultural fair or event Live animal market Petting zoo

Veterinary care Slaughterhouse Other

101. 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

102. Did the patient clean any poultry pens/houses in the 10 days before becoming ill?

Yes No Unknown

103. Did the patient feed or water any poultry in the 10 days before becoming ill?

Yes No Unknown

104. 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

105. Did the patient participate in the culling of any poultry flocks?

Yes No (skip to Q.109) Unknown (skip to Q.109)

106. What measures did the patient use to protect himself/herself during the culling (check all that apply)?

None Facemask Respirators Hand gloves Eye Protection Gowns Boots Unknown Other

107. 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 mentioned in Q. 107)?

% Facemask % Respirators % Hand gloves % Eye protection % Gowns % Boots

% Other

108. In the 10 days before becoming ill, on what days did the patient have direct or any other exposure 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

109. From Q.109, what was the total number of different days the patient reported direct or any other bird or poultry exposure? days

110. Did the patient report direct or any other exposure (direct or any other exposure or both) with any ill-appearing poultry in the 10 days before becoming ill?

Yes, specify No Unknown

111. Did the patient report direct or any other exposure (direct, or any other exposure, or both) with dead poultry in the 10 days before becoming ill?

Yes, specify No Unknown

Avian Module continued– complete only if confirmed case with an avian influenza virus (i.e. H5N1, H7N9)

R isk Factors—Household bird and poultry practices

112. Were poultry raised on the patient’s property?

Yes No (skip to Q.121) Unknown (skip to Q.121)

113. 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

114. 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 #

115. Did the patient’s household have any recent (within the past 30 days) ill-appearing poultry? Yes No Unknown

116. Did the patient’s household have any recent poultry die-offs?

Yes No (skip to Q.121) Unknown (skip to Q.121)

117. Please indicate the percent of the flock that died. %

118. When did the die-off begin and end? Begin date: / / (MM/DD/YYYY) End date: / / (MM/DD/YYYY)

119. Was the flock culled?

Yes (date / / MM/DD/YY) No Unknown

120. 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

121. Did the patient consume raw or undercooked poultry in the 10 days before becoming ill? Yes No Unknown

122. 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

123. Were there any recent reports of sick or dead poultry in the case patient’s area?

Yes, specify No Unknown

124. Were captive wild birds kept at the patient’s residence?

Yes (describe) No Unknown

125. 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

126. In the 10 days before illness onset, did the patient have direct or any other exposure (touch or handle or touch potentially contaminated surfaces, walk through an area containing, or come within 6 feet of) to wild/migratory birds?

Yes No (skip to Q.132) Unknown (skip to Q.132)

127. 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

128. In the 10 days before becoming ill, did the patient have any other exposure to (touch potentially contaminated surfaces, walk through an area containing, or come within 6 feet of) any wild/migratory birds?

Yes, specify type of bird(s) No Unknown

129. Were any of the wild/migratory birds that the patient had direct or any other contact with sick or dying?

Yes, specify No Unknown

Avian Module continued– complete only if confirmed case with an avian influenza virus (i.e. H5N1, H7N9)

130. In the 10 days before becoming ill, on what days did the patient have direct or any other exposure (touch or handle or touch potentially contaminated surfaces, walk through an area containing, or come within 6 feet of) 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

131. In the 10 days before becoming ill, did the patient have direct or any other exposure with birds other than poultry or wild/migratory birds?

Yes, specify type of bird(s) No (skip to Q.135) Unknown (skip to Q135.)

132. Were any of these birds that the patient had direct or any other exposure with sick or dying?

Yes, specify No Unknown

133. In the 10 days before becoming ill, on what days did the patient have direct or any other exposure 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

135. In the 10 days before becoming ill, did the patient have direct contact (touch or handle) with livestock (cattle, goats, sheep, pigs, etc.)?

Yes No (skip to Q.138) Unknown (skip to Q.138)

136. Where did the direct contact with livestock occur (check all that apply)?

Home Commercial farm Agricultural fair or event Live animal market Petting zoo Veterinary care Slaughterhouse Other

137. What type(s) of livestock did the patient have direct contact with (check all that apply)?

Cattle Sheep Goats Other

138. 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) livestock?

Yes No (skip to Q.141) Unknown (skip to Q.141)

139. Where did this exposure from Q.138 to livestock occur (check all that apply)?

Home Commercial farm Agricultural fair or event Live animal market Petting zoo Veterinary care Slaughterhouse/rendering facility Other

140. What type(s) of livestock did the patient have this exposure to from Q.138 (check all that apply)?

Cattle Sheep Goats Other

141. Did the patient conduct any of the following activities in the 10 days before becoming ill (check all that apply)?

Work at a farm or facility where live animals are present Touch, handle, or otherwise interact with ill livestock (cattle, goats, sheep)

Touch, handle, or otherwise interact with ill wild animals Drink or handle raw or unpasteurized milk

Consume or handle raw or unpasteurized milk products (cheese, cream, kefir, etc.) Work in a maternity or reproductive area of a farm

Handle or clean up animal stool or manure Use a pressure washer or broom in an area contaminated by animal manure or milk

Operate or clean automated milking equipment Perform manual milking of animals

142. Did the patient clean any livestock pens in the 10 days before becoming ill?

Yes No Unknown

143. Did the patient feed or water any livestock in the 10 days before becoming ill?

Yes No Unknown

144. Did the patient have direct contact with surfaces contaminated by livestock, livestock manure, livestock milk, or livestock parts (carcasses, internal organs, reproductive tissues, etc.) in the 10 days before becoming ill?

Yes No Unknown

145. What measures did the patient use to protect himself/herself when exposed to livestock (check all that apply)?

None Facemask Respirators Hand gloves Eye Protection Gowns Boots Unknown

Other

146. What percentage of time did the person wear the items mentioned above while exposed to livestock (only ask about the items the exposed person mentioned in Q. 146)?

% Facemask % Respirators % Hand gloves % Eye protection % Gowns % Boots

% Other

147. In the 10 days before becoming ill, on what days did the patient have direct or any other exposure (touch or handle or touch potentially contaminated surfaces, walk through an area containing, or come within 6 feet of) to livestock (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

148. Did the patient report direct or any other exposure to any livestock that appeared ill in the 10 days before becoming ill?

Yes, specify No Unknown

149. Did the patient report direct or any other exposure to dead livestock in the 10 days before becoming ill?

Yes, specify No Unknown

R isk Factors—Human exposures

1. Please describe bird/poultry/livestock exposure for all household members listed in Q.72 of the main Novel A Case Report Form (please use the same ID as in Q.72).

ID	If HH member was ILL						If HH member was NOT ILL
	Did HH member have any bird exposure ≤10 days before his/her onset?			Did HH member visit a live market ≤10 days before his/her onset?			Did HH member have any bird exposure or visit a live market visit ≤10 days before the case-patient’s illness onset?
1	Y	N	U	Y	N	U	Y	N	U
2	Y	N	U	Y	N	U	Y	N	U
3	Y	N	U	Y	N	U	Y	N	U
4	Y	N	U	Y	N	U	Y	N	U
5	Y	N	U	Y	N	U	Y	N	U
6	Y	N	U	Y	N	U	Y	N	U

2. Please describe the bird exposure and live market visits for individuals listed in Q.72 of the main Novel A Case Report Form.

ID	Any bird exposure or live market visits ≤10 days before his/her onset?	Comments
1	Y N U
2	Y N U
3	Y N U
4	Y N U

3. Please describe the bird exposure and live market visits of individuals listed in Q.72 of the main Novel A Case Report Form.

ID	Any bird exposure or live market visits ≤10 days before his/her onset?	Comments
1	Y N U
2	Y N U
3	Y N U
4	Y N U

4. 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

5. Notes: