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pdfInfluenza
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:
Site Use 1:
Site Use 2:
Site Use 3:
No PCP
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 and/or Ethnicity (select all that apply):
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Multiracial, not otherwise specified
Native Hawaiian or Pacific Islander
White
Unknown
9. Was patient discharged
from any hospital within
1 week prior to the current
admission date?
13. Was patient transferred from another hospital?
Yes
No
Unknown
4. Case Type:
Pediatric
Adult
3. County:
Yes
No
Unknown
5. Date of Birth:
10. Type of Insurance (select all that apply):
Private
Medicare
Medicaid/state assistance program
Military
Indian Health Service
Incarcerated
Uninsured
Unknown
Other, specify:
13a. Transfer Hospital ID:
6. Age:
7. Sex:
Years
Male
Months (if < 1 yr)
Female
Days (if < 1 month)
11. Pregnant? (15-49 years of age only):
Yes
No/Unknown
Not applicable
(male/pregnant outside of applicable age range)
12. Hospital ID Where Patient Treated:
12a. Admission Date:
12b. Discharge Date:
13b. Transfer Hospital Admission Date:
13c. Transfer Date:
14. 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/Behavioral
Health Facility
Other long term care facility
Unknown
Other, specify:
14a. If resident of a facility indicate NAME of facility:
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).
06/06/2024
Page 1 of 9
FSN 300.1
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Case ID:
D. Influenza Testing Results (can add up to 4 test results in database)
1. Test 1:
Rapid Antigen
Standard/Rapid Molecular Assay
Viral Culture
Fluorescent Antibody
1a. Result:
Flu A (no subtype)
2009 H1N1
H1, Unspecified
Flu A, Unsubtypable
Flu B (no lineage)
Flu B, Victoria
H1, Seasonal
H1
H3
1b. Specimen collection date:
Method Unknown
Flu B, Yamagata
Flu A & B
Flu A/B (not distinguished)
1c. Specimen ID:
2. Test 2:
Rapid Antigen
Standard/Rapid Molecular Assay
Viral Culture
Fluorescent Antibody
2a. Result:
Flu A (no subtype)
2009 H1N1
H1, Unspecified
Flu A, Unsubtypable
Flu B (no lineage)
Flu B, Victoria
H1, Seasonal
H1
H3
2b. Specimen collection date:
Rapid Antigen
Standard/Rapid Molecular Assay
Viral Culture
Fluorescent Antibody
3a. Result:
Flu A (no subtype)
2009 H1N1
H1, Unspecified
Flu A, Unsubtypable
Flu B (no lineage)
Flu B, Victoria
H1, Seasonal
H1
H3
3b. Specimen collection date:
Other, please specify:
1d. Testing facility ID:
Method Unknown
Flu B, Yamagata
Flu A & B
Flu A/B (not distinguished)
2c. Specimen ID:
3. Test 3:
Unknown Type
Negative
H3N2v
Unknown Type
Negative
H3N2v
Other, please specify:
2d. Testing facility ID:
Method Unknown
Flu B, Yamagata
Flu A & B
Flu A/B (not distinguished)
3c. Specimen ID:
Unknown Type
Negative
H3N2v
Other, please specify:
3d. Testing facility ID:
E. Other Interventions and ICU (For Questions 1-5, select the highest level of oxygen support received)
1. BiPAP or CPAP?
Yes
No
2. High flow nasal cannula (e.g., Vapotherm)?
Unknown
4. ECMO?
Yes
No
Unknown
3. Invasive mechanical ventilation?
Yes
5. Supplemental Oxygen?
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
No
Unknown
No
7. Was the patient admitted to an intensive care unit (ICU)?
7a. Date of 1st ICU Admission:
Unknown
Yes
Unknown
No
Yes
No
Unknown
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/Behavioral Health Facility
Other long term care facility
Against medical advice (AMA)
Discharged to another hospital
Other, specify:
Unknown
3. Additional notes regarding discharge:
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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
Shortness of breath/
respiratory distress/hypoxia
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
7. Smoker (tobacco) (for patients > 12 years):
Current
Former
No/Unknown
9. Alcohol misuse (for patients > 12 years):
Current
Former
No/Unknown
Unknown
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):
Yes
No
Unknown
10. Substance misuse (for patients > 12 years):
Current
Former
No/Unknown
11. Substance Misuse Type or Route (current use only) (Select all that apply) :
Cocaine
IVDU
Opioids
12. Code status on admission:
06/06/2024
Polysubstance abuse - not otherwise specified
Methamphetamines
Marijuana
Full code
DNR/DNI/CMO
Other, specify:
Unknown
Unknown
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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. Diabetes Mellitus (DM):
Yes
No/Unknown
1d. Chronic Metabolic Disease:
Yes
No/Unknown
Adrenal Disorders (Addison’s disease, adrenal insufficiency,
Cushing syndrome, congenital adrenal hyperplasia)
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)
1e.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
06/06/2024
Yes
1f. Hypertension (HTN):
No
Unknown
Yes
No/Unknown
1g. 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
Patent Ductus Arteriosus (PDA)
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
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H. Underlying Medical Conditions (continued)
1h. 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
1i. History of Guillain-Barre Syndrome:
No/Unknown
Yes
1j. 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
1k. 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)
1l Any Obesity:
Yes
Obese
Severely/morbidly obese (ADULTS ONLY)
No/Unknown
1m. Post-partum (two weeks or less):
No/Unknown
06/06/2024
Yes
1n. Gastrointestinal/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)
1o. 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)
1p. Mental Health Conditions:
Bipolar disorder
Depression
Schizophrenia spectrum disorder
No/Unknown
Yes
No/Unknown
1q. Other:
Yes
Bedbound
Feeding tube dependent (PEG, see list)
Trach dependent/Vent dependent
Wheelchair dependent
Other, specify:
No/Unknown
1r. 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
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I. 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. Coronavirus SARS-CoV-2
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1c. Adenovirus
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1d. Parainfluenza 1
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1e. Parainfluenza 2
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1f. Parainfluenza 3
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1g. Parainfluenza 4
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1h. Human metapneumovirus
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1i. Rhinovirus/Enterovirus
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1j. Coronavirus 229E
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1k. Coronavirus HKU1
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1l. Coronavirus NL63
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1m. Coronavirus OC43
Yes, positive
Yes, negative
Not tested/Unknown
Date:
1n. Coronavirus (not further specified)
Yes, positive
Yes, negative
Not tested/Unknown
Date:
No
Unknown
J. Influenza Treatment (can add up to 4 treatment courses in database)
1. Did the patient receive treatment for influenza?
1a. Treatment 1:
Baloxavir marboxil (Xofluza)
Oseltamivir (Tamiflu)
1b. Start date:
2a. Treatment 2:
Yes
No
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:
K. Chest X-ray – Based on radiology report only
1. Was a chest x-ray taken during the first 3 days of admission (for patients ≤17 years)?
06/06/2024
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Yes
No
Unknown
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L. 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
M. 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.
N. Pregnancy Information - To be completed for pregnant women only
1. Total # of pregnancies to date as of date of admission
(Gravida, G):
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:
3. Specify total # of fetuses for current pregnancy
as of date of admission
1
2
3
>3
Unknown
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
6. Indicate pregnancy status at discharge or death:
Pre-eclampsia
Pregnancy-induced hypertension (PIH)
Still pregnant
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:
06/06/2024
Intrauterine growth restriction (IUGR)
Unknown
Unknown
6b. Pre-term live birth? (< 37 weeks GA)
Yes
No
Unknown
Preterm delivery, gestational age in weeks:
Unknown
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O. 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
Injected Vaccine
3. Primary Care Provider /LTCF:
Yes, full date known
Yes, specific date unknown
Not Checked
Unsuccessful Attempt
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:
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
2b. If patient < 9 yrs, specify vaccine type:
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
Date Unknown
P. Additional Comments
06/06/2024
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R. COVID-19 Vaccine History (Additional products will be listed in the database as FDA authorization/emergency use authorization received)
1. Vaccine registry:
Registry reviewed
Registry available but not reviewed (specify):
Registry not available for review
2. COVID-19 vaccine doses received (For cases ≥ 6 years old, record all doses of COVID-19 vaccine received on/after August 31, 2022. For cases < 6 years old, record all available
doses of COVID-19 vaccine)
FOR COVID-NET CASE PATIENTS ≥ 6 YEARS OLD:
Dose Date
Dose Product
Month Day
Vaccines available as of Fall 2023
2023 Pfizer-BioNTech COVID-19 Vaccine, Monovalent (XBB.1.5)
2023 Moderna COVID-19 Vaccine, Monovalent (XBB.1.5)
Unk.
Unk.
Year
Unk.
Dose Source
Registry
Vaccines available prior to Fall 2023
fizer-BioNTech COVID-19 Vaccine, Bivalent (COMIRNATY/ bivalent BNT162b2 -orP
Original and Omicron BA.4/BA.6)
Moderna COVID-19 Vaccine, Bivalent (mRNA-1273.214)
Janssen Pharmaceuticals (JNJ-78436735)
Novavax COVID-19 Vaccine, Adjuvanted (NVX-CoV2373, Covovax)
AstraZeneca (AZD1222)
Unknown
Other, specify:
FOR COVID-NET CASE-PATIENTS ≥ 6 MONTHS- <6 YEARS OLD:
Dose Date
Dose Product
Month Day
Vaccines available as of Fall 2023
2023 Pfizer-BioNTech COVID-19 Vaccine, Monovalent (XBB.1.5)
2023 Moderna COVID-19 Vaccine, Monovalent (XBB.1.5)
Unk.
Unk.
Year
Unk.
Dose Source
Registry
Vaccines available prior to Fall 2023
Pfizer-BioNTech COVID-19 Vaccine, Bivalent (COMIRNATY)
Moderna COVID-19 Vaccine, Bivalent (Spikevax)
Pfizer-BioNTech COVID-19 Vaccine, Monovalent or (COMIRNATY/ Monovalent BNT162b2)
Moderna COVID-19 Vaccine, Monovalent (Spikevax, mRNA-1273)
Unknown
Other, specify:
Page 9 of 9
CS341635-A
| File Type | application/pdf |
| Subject | 2024–2025 Influenza Hospitalization Surveillance Network (FluSurv-NET) Case Report Form |
| Author | Centers for Disease Control and Prevention |
| File Modified | 2024-06-11 |
| File Created | 2024-06-11 |