Form CDC 57.210 CDC 57.210 HCW Prophylaxis/Treatment-Influenza

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Healthcare Worker Prophylaxis/Treatment

Influenza

Page 1 of 4

*required

Facility ID #:

Med Admin #:

Healthcare Worker Demographics

*HCW ID#:

*HCW Name, Last:

First:

Middle:

*Gender: □ F □ M □ Other

*Date of Birth: ____ / ____ /_______

*Work Location:

*Occupation:

Clinical Specialty:

Information about the Antiviral Medication

Infectious agent: Influenza

*For season: _____________________(specify years)

*Indication (select one)

*#

Influenza subtype

*Antiviral medication (Enter code from below)

*Start date

Stop date

*Adverse reactions

□ Prophylaxis □ Treatment

□ Seasonal □ Non-seasonal □ Unknown

___/___/____ mm dd yyyy

___/___/____ mm dd yyyy

□ Yes □ No □ Don’t know

□ Prophylaxis □ Treatment

□ Seasonal □ Non-seasonal □ Unknown

___/___/____ mm dd yyyy

___/___/____ mm dd yyyy

□ Yes □ No □ Don’t know

□ Prophylaxis □ Treatment

□ Seasonal □ Non-seasonal □ Unknown

___/___/____ mm dd yyyy

___/___/____ mm dd yyyy

□ Yes □ No □ Don’t know

□ Prophylaxis □ Treatment

□ Seasonal □ Non-seasonal □ Unknown

___/___/____ mm dd yyyy

___/___/____ mm dd yyyy

□ Yes □ No □ Don’t know

□ Prophylaxis □ Treatment

□ Seasonal □ Non-seasonal □ Unknown

___/___/____ mm dd yyyy

___/___/____ mm dd yyyy

□ Yes □ No □ Don’t know

□ Prophylaxis □ Treatment

□ Seasonal □ Non-seasonal □ Unknown

___/___/____ mm dd yyyy

___/___/____ mm dd yyyy

□ Yes □ No □ Don’t know

□ Prophylaxis □ Treatment

□ Seasonal □ Non-seasonal □ Unknown

___/___/____ mm dd yyyy

___/___/____ mm dd yyyy

□ Yes □ No □ Don’t know

□ Prophylaxis □ Treatment

□ Seasonal □ Non-seasonal □ Unknown

___/___/____ mm dd yyyy

___/___/____ mm dd yyyy

□ Yes □ No □ Don’t know

□ Prophylaxis □ Treatment

□ Seasonal □ Non-seasonal □ Unknown

___/___/____ mm dd yyyy

___/___/____ mm dd yyyy

□ Yes □ No □ Don’t know

□ Prophylaxis □ Treatment

□ Seasonal □ Non-seasonal □ Unknown

___/___/____ mm dd yyyy

___/___/____ mm dd yyyy

□ Yes □ No □ Don’t know

Antiviral medications

AMAN-amantadine (Symmetrel®)

RIMAN-rimantadine(Flumadine®)

ZANAM-zanamivir (Relenza®)

OSELT-oseltamivir (Tamiflu®)

Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 10 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, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.210 (Front), v6.6

Healthcare Worker Influenza Antiviral Medication Administration

Page 2 of 4
Information about the Antiviral Medication (cont.)
Adverse reactions to antiviral medication #1: (check all that apply)
□ Acute respiratory failure	□ Hemorrhagic colitis	□ Pulmonary edema
□ Anaphylactic reaction	□ Hepatitis	□ Serious skin rash
□ Arrhythmia	□ Hypotension; orthostatic hypotension	□ Suicide or self-harm attempt
□ Behavior disturbances	□ Leukopenia; neutropenia	□ Swelling of face or tongue
□ Bronchospasm	□ Life threatening overdose	□ Syncope
□ Cardiac arrest	□ Liver function test elevation	□ Tachycardia
□ Cardiac failure	□ Mydriasis (in patients with untreated angle closure glaucoma)	□ Toxic epidermal necrolysis/Stevens Johnson Syndrome
□ Coma	□ Neuroleptic malignant syndrome with abrupt discontinuation or dose reduction	□ Urinary retention
□ Convulsions; seizure		□ Other: _______________
□ Delirium, delusions, stupor	□ Oropharyngeal edema
□ Erythema multiforme	□ Psychosis
Adverse reactions to antiviral medication #2: (check all that apply)
□ Acute respiratory failure	□ Hemorrhagic colitis	□ Pulmonary edema
□ Anaphylactic reaction	□ Hepatitis	□ Serious skin rash
□ Arrhythmia	□ Hypotension; orthostatic hypotension	□ Suicide or self-harm attempt
□ Behavior disturbances	□ Leukopenia; neutropenia	□ Swelling of face or tongue
□ Bronchospasm	□ Life threatening overdose	□ Syncope
□ Cardiac arrest	□ Liver function test elevation	□ Tachycardia
□ Cardiac failure	□ Mydriasis (in patients with untreated angle closure glaucoma)	□ Toxic epidermal necrolysis/Stevens Johnson Syndrome
□ Coma	□ Neuroleptic malignant syndrome with abrupt discontinuation or dose reduction	□ Urinary retention
□ Convulsions; seizure		□ Other: _______________
□ Delirium, delusions, stupor	□ Oropharyngeal edema
□ Erythema multiforme	□ Psychosis
Adverse reactions to antiviral medication #3: (check all that apply)
□ Acute respiratory failure	□ Hemorrhagic colitis	□ Pulmonary edema
□ Anaphylactic reaction	□ Hepatitis	□ Serious skin rash
□ Arrhythmia	□ Hypotension; orthostatic hypotension	□ Suicide or self-harm attempt
□ Behavior disturbances	□ Leukopenia; neutropenia	□ Swelling of face or tongue
□ Bronchospasm	□ Life threatening overdose	□ Syncope
□ Cardiac arrest	□ Liver function test elevation	□ Tachycardia
□ Cardiac failure	□ Mydriasis (in patients with untreated angle closure glaucoma)	□ Toxic epidermal necrolysis/Stevens Johnson Syndrome
□ Coma	□ Neuroleptic malignant syndrome with abrupt discontinuation or dose reduction	□ Urinary retention
□ Convulsions; seizure		□ Other: _______________
□ Delirium, delusions, stupor	□ Oropharyngeal edema
□ Erythema multiforme	□ Psychosis
Adverse reactions to antiviral medication #4: (check all that apply)
□ Acute respiratory failure	□ Hemorrhagic colitis	□ Pulmonary edema
□ Anaphylactic reaction	□ Hepatitis	□ Serious skin rash
□ Arrhythmia	□ Hypotension; orthostatic hypotension	□ Suicide or self-harm attempt
□ Behavior disturbances	□ Leukopenia; neutropenia	□ Swelling of face or tongue
□ Bronchospasm	□ Life threatening overdose	□ Syncope
□ Cardiac arrest	□ Liver function test elevation	□ Tachycardia
□ Cardiac failure	□ Mydriasis (in patients with untreated angle closure glaucoma)	□ Toxic epidermal necrolysis/Stevens Johnson Syndrome
□ Coma	□ Neuroleptic malignant syndrome with abrupt discontinuation or dose reduction	□ Urinary retention
□ Convulsions; seizure		□ Other: _______________
□ Delirium, delusions, stupor	□ Oropharyngeal edema
□ Erythema multiforme	□ Psychosis

Healthcare Worker Influenza Antiviral Medication Administration

Page 3 of 4
Information about the Antiviral Medication (cont.)
Adverse reactions to antiviral medication #5: (check all that apply)
□ Acute respiratory failure	□ Hemorrhagic colitis	□ Pulmonary edema
□ Anaphylactic reaction	□ Hepatitis	□ Serious skin rash
□ Arrhythmia	□ Hypotension; orthostatic hypotension	□ Suicide or self-harm attempt
□ Behavior disturbances	□ Leukopenia; neutropenia	□ Swelling of face or tongue
□ Bronchospasm	□ Life threatening overdose	□ Syncope
□ Cardiac arrest	□ Liver function test elevation	□ Tachycardia
□ Cardiac failure	□ Mydriasis (in patients with untreated angle closure glaucoma)	□ Toxic epidermal necrolysis/Stevens Johnson Syndrome
□ Coma	□ Neuroleptic malignant syndrome with abrupt discontinuation or dose reduction	□ Urinary retention
□ Convulsions; seizure		□ Other: _______________
□ Delirium, delusions, stupor	□ Oropharyngeal edema
□ Erythema multiforme	□ Psychosis
Adverse reactions to antiviral medication #6: (check all that apply)
□ Acute respiratory failure	□ Hemorrhagic colitis	□ Pulmonary edema
□ Anaphylactic reaction	□ Hepatitis	□ Serious skin rash
□ Arrhythmia	□ Hypotension; orthostatic hypotension	□ Suicide or self-harm attempt
□ Behavior disturbances	□ Leukopenia; neutropenia	□ Swelling of face or tongue
□ Bronchospasm	□ Life threatening overdose	□ Syncope
□ Cardiac arrest	□ Liver function test elevation	□ Tachycardia
□ Cardiac failure	□ Mydriasis (in patients with untreated angle closure glaucoma)	□ Toxic epidermal necrolysis/Stevens Johnson Syndrome
□ Coma	□ Neuroleptic malignant syndrome with abrupt discontinuation or dose reduction	□ Urinary retention
□ Convulsions; seizure		□ Other: _______________
□ Delirium, delusions, stupor	□ Oropharyngeal edema
□ Erythema multiforme	□ Psychosis
Adverse reactions to antiviral medication #7: (check all that apply)
□ Acute respiratory failure	□ Hemorrhagic colitis	□ Pulmonary edema
□ Anaphylactic reaction	□ Hepatitis	□ Serious skin rash
□ Arrhythmia	□ Hypotension; orthostatic hypotension	□ Suicide or self-harm attempt
□ Behavior disturbances	□ Leukopenia; neutropenia	□ Swelling of face or tongue
□ Bronchospasm	□ Life threatening overdose	□ Syncope
□ Cardiac arrest	□ Liver function test elevation	□ Tachycardia
□ Cardiac failure	□ Mydriasis (in patients with untreated angle closure glaucoma)	□ Toxic epidermal necrolysis/Stevens Johnson Syndrome
□ Coma	□ Neuroleptic malignant syndrome with abrupt discontinuation or dose reduction	□ Urinary retention
□ Convulsions; seizure		□ Other: _______________
□ Delirium, delusions, stupor	□ Oropharyngeal edema
□ Erythema multiforme	□ Psychosis
Adverse reactions to antiviral medication #8: (check all that apply)
□ Acute respiratory failure	□ Hemorrhagic colitis	□ Pulmonary edema
□ Anaphylactic reaction	□ Hepatitis	□ Serious skin rash
□ Arrhythmia	□ Hypotension; orthostatic hypotension	□ Suicide or self-harm attempt
□ Behavior disturbances	□ Leukopenia; neutropenia	□ Swelling of face or tongue
□ Bronchospasm	□ Life threatening overdose	□ Syncope
□ Cardiac arrest	□ Liver function test elevation	□ Tachycardia
□ Cardiac failure	□ Mydriasis (in patients with untreated angle closure glaucoma)	□ Toxic epidermal necrolysis/Stevens Johnson Syndrome
□ Coma	□ Neuroleptic malignant syndrome with abrupt discontinuation or dose reduction	□ Urinary retention
□ Convulsions; seizure		□ Other: _______________
□ Delirium, delusions, stupor	□ Oropharyngeal edema
□ Erythema multiforme	□ Psychosis

Healthcare Worker Influenza Antiviral Medication Administration

Page 4 of 4
Information about the Antiviral Medication (cont.)
Adverse reactions to antiviral medication #9: (check all that apply)
□ Acute respiratory failure	□ Hemorrhagic colitis			□ Pulmonary edema
□ Anaphylactic reaction	□ Hepatitis			□ Serious skin rash
□ Arrhythmia	□ Hypotension; orthostatic hypotension			□ Suicide or self-harm attempt
□ Behavior disturbances	□ Leukopenia; neutropenia			□ Swelling of face or tongue
□ Bronchospasm	□ Life threatening overdose			□ Syncope
□ Cardiac arrest	□ Liver function test elevation			□ Tachycardia
□ Cardiac failure	□ Mydriasis (in patients with untreated angle closure glaucoma)			□ Toxic epidermal necrolysis/Stevens Johnson Syndrome
□ Coma	□ Neuroleptic malignant syndrome with abrupt discontinuation or dose reduction			□ Urinary retention
□ Convulsions; seizure				□ Other: _______________
□ Delirium, delusions, stupor	□ Oropharyngeal edema
□ Erythema multiforme	□ Psychosis
Adverse reactions to antiviral medication #10: (check all that apply)
□ Acute respiratory failure	□ Hemorrhagic colitis			□ Pulmonary edema
□ Anaphylactic reaction	□ Hepatitis			□ Serious skin rash
□ Arrhythmia	□ Hypotension; orthostatic hypotension			□ Suicide or self-harm attempt
□ Behavior disturbances	□ Leukopenia; neutropenia			□ Swelling of face or tongue
□ Bronchospasm	□ Life threatening overdose			□ Syncope
□ Cardiac arrest	□ Liver function test elevation			□ Tachycardia
□ Cardiac failure	□ Mydriasis (in patients with untreated angle closure glaucoma)			□ Toxic epidermal necrolysis/Stevens Johnson Syndrome
□ Coma	□ Neuroleptic malignant syndrome with abrupt discontinuation or dose reduction			□ Urinary retention
□ Convulsions; seizure				□ Other: _______________
□ Delirium, delusions, stupor	□ Oropharyngeal edema
□ Erythema multiforme	□ Psychosis
Custom Fields
Label			Label
_________________________		____/____/_____	_______________________		____/____/_____
_________________________		______________	_______________________		______________
_________________________		______________	_______________________		______________
_________________________		______________	_______________________		______________
_________________________		______________	_______________________		______________
_________________________		______________	_______________________		______________
_________________________		______________	_______________________		______________
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