0920-0004 Novel Influenza A Virus Case Screening Form 06MAY2024

Novel Influenza A Virus Case Screening Form

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

Reporting county:			Case residence county:					Case phone:
Interviewer name:			Phone:					Email:
Case name:			Parent/guardian name (for minors):
Please send the portion below to the Influenza Division at CDC (email: [email protected])
Date of report: (mm/dd/yyyy):______________				☐New report ☐Update to previous report			Person reporting: __________________ Contact phone: ____________________
State Case ID #:					Specimen Collection Date (mm/dd/yyyy):
What is the subtype? (Required) ☐Influenza A(H1N1) variant ☐Influenza A(H1N2) variant ☐Influenza A(H3N2) variant ☐Influenza A(H5N1)	☐Influenza A(H7N9) ☐Unknown ☐Other _______________­				State Lab Specimen ID #1:
					State Lab Specimen ID #2:
					Was the specimen submitted to CDC? ☐Yes ☐No ☐Unknown
At the time of this report, is the case ☐Confirmed ☐Probable ☐Under Investigation ☐Not a Case
State of Residence:		Country of usual residence:				If usual resident of U.S., County of Residence:
Date of Birth (mm/dd/yyyy):					Sex: ☐Male ☐Female
Age: ______ Age Type: ☐Days ☐Weeks ☐Months ☐Years
Did the patient have any of the following symptoms: fever or feeling feverish/chills; cough; sore throat; runny or stuffy nose; eye tearing, redness, irritation (“pink eye”); sneezing; difficulty breathing; shortness of breath; fatigue (feeling very tired); muscle or body aches; headaches; nausea; vomiting; diarrhea; seizures; or rash? ☐Yes ☐No ☐Unknown
Illness Onset Date (mm/dd/yyyy):					Hospitalized? ☐Yes ☐No ☐Unknown
ICU? ☐Yes ☐No ☐Unknown					Death? ☐Yes ☐No ☐Unknown				Date of Death (mm/dd/yyyy):
Contact of a confirmed case? ☐Yes ☐No ☐Unknown					Employed at a health care facility? ☐Yes ☐No ☐Unknown
Any animal exposure in 10 days prior to illness onset? ☐Yes ☐No ☐Unknown
What type(s) of animals was the patient exposed to? ☐Horses ☐Cows ☐Poultry/wild birds ☐Sheep ☐Goats ☐Pigs/hogs ☐Other (1)___________­__­__ ☐Other (2)__________­­_____ ☐Other (3)______________­__­­­ ☐Other (4)_________________
Where did this animal exposure occur? (select all that apply) ☐Participated in a depopulation event ☐Worked or lived on farm where HPAI was detected ☐Hunted and harvested a wild bird ☐Attended agricultural event/live animal market ☐Other, specify: _________________					If participated in a depopulation event or worked or lived on a farm where HPAI was detected, indicate the outbreak ID (if patient was being monitored due to mobilization for poultry outbreak, enter the outbreak ID here):
Notes/Comments:

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D‐74, Atlanta, Georgia 30333; ATTN: PRA (0920‐0004).

• For CUIs, arrange for nasopharyngeal (NP) swab collection and RT-PCR testing at a state public health laboratory.

• Patients with influenza-like illness should discuss possible antiviral treatment with a healthcare provider.

• Healthcare facilities should use appropriate isolation precautions for cases under investigation for infection with novel influenza A viruses. Non-hospitalized cases under investigation should stay home from school, work, and social gatherings until fever is gone for at least 24 hours without the use of fever-reducing medications.

• If this case is later determined to be a confirmed case of infection with novel influenza A, please notify CDC and complete the CDC Human Infection with Novel Influenza A Virus Case Report Form.