Form assinged Legionellosis

– LEGIONELLOSIS CASE REPORT –

Patient’s Name: ______________________________________________________________________________________ ____________________________
(Last, First, M.I.)

Hospital: ________________________________

(Telephone No.)

Address: ___________________________________________________________________________________________________ ____________________
(Number, Street, Apt. No., City, State)

Patient Chart No.: ________________________

(Zip Code)

-- Patient identifier information is not transmitted to CDC --

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Disease Control
and Prevention (CDC)

LEGIONELLOSIS CASE REPORT

Atlanta, Georgia 30333

(DISEASE CAUSED BY ANY LEGIONELLA SPECIES)
Form Approved OMB No. 0920-0009

– PATIENT INFORMATION –
1. State Health Dept. Case No.

2. Reporting
State:

3. (CDC Use Only)

4. County of Residence

5. State of
Residence

6. Occupation:

Case
No.

7a. Date of Birth:
Mo.

7b. Age:

Day

8. Sex:

1 ■ Days

Year

9. Ethnicity:

■ Unk
■
2 ■ Not Hispanic/Latino

■ Male
2 ■ Female

2 ■ Mos.

1

1

3 ■ Years

10. Race:
American Indian/
Alaskan Native

■
2 ■ Asian

Hispanic/
9
Latino

1

■ Black or African American
Native Hawaiian or Other
4 ■ Pacific Islander
5 ■ White
9 ■ Unk
3

11. Possible sources of exposure:
IN THE TWO WEEKS BEFORE ONSET, DID PATIENT:

a) Travel or stay overnight somewhere other than usual residence?
1

■ Yes

2

■ No

9

■ Unk

If Yes, give cities and
lodging where available:

CITY

LODGING

___________________________________________

________________________________________________

___________________________________________

________________________________________________

___________________________________________

________________________________________________

* For suspected travel related cases, please contact CDC or pertinent state health departments immediately.

b) Have dental work?

1

■ Yes

2

■ No

9

■ Unk

If Yes, name of
dental office:

c) Visit a hospital as an outpatient?

1

■ Yes

2

■ No

9

■ Unk

If Yes, name of hospital: __________________________________________________________________

d) Work in a hospital?

1

■ Yes

2

■ No

9

■ Unk

If Yes, name of hospital: __________________________________________________________________

__________________________________________________________________

12. Was case hospital related (nosocomial)?
2

■ Not nosocomial: No inpatient or outpatient hospital

3

1

■ Definitely nosocomial: Patient hospitalized continuously

8

■ Possibly nosocomial: Patient hospitalized

2 - 9 days before onset of legionella infection.

visits in the 10 days prior to onset of symptoms.

for ≥ 10 days before onset of legionella infection.

9

■ Unk

■ Other(Specify) _________________________________________________________________________________

13. Was this patient’s legionella infection: (check one)

■ Associated with outbreak (Specify location): ______________________________________________________________________________________________________________
2 ■ Sporadic case
9 ■ Unk
1

– CLINICAL ILLNESS –
14. Diagnosis: (check one)

■ Legionnaires’ Disease (Pneumonia, X-ray diagnosed)
2 ■ Pontiac fever (fever, myalgia without pneumonia)
1

15. Date of symptom onset
of Legionellosis
Mo.

Day

Year

■ Other (Specify) _________________________________________________________________________________
9 ■ Unk
8

16. Was patient hospitalized
for Legionellosis?
1

■ Yes

2

■ No

9

■ Unk

Hospital
_____________________________________________________
name:
Hospital
address: _____________________________________________________
_____________________________________________________

17. Outcome of illness:
1

■ Survived

2

■ Died

9

■ Unk

_____________________________________________________

– CASE DEFINITION –
Confirmed case has a compatible clinical history and meets at least one of the following criteria:
1) isolation of Legionella species from lung tissue, respiratory secretions, pleural fluid, blood or other sterile site
2) demonstration of L. pneumophila, serogroup 1, in lung tissue, respiratory secretions, or pleural fluid by direct fluorescent antibody testing
3) fourfold or greater rise in immunoflourescent antibody titer to L. pneumophila, serogroup 1, to 128 or greater
4) detection of L. pneumophila serogroup 1 antigen in urine
Public reporting burden of this collection of information is estimated to average 20 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, Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0009). Do not send the completed form to this address. While your response is
voluntary your cooperation is necessary for the understanding and control of this disease.
CDC 52.56 Rev. 02/2003

– LEGIONELLOSIS CASE REPORT –

Page 1 of 2

– LEGIONELLOSIS CASE REPORT –

– METHOD OF DIAGNOSIS –
PLEASE CHECK ALL METHODS OF DIAGNOSIS WHICH APPLY
1

■ Culture Positive:

If Yes,
Date:

Mo.

Day

Year

Site: 1

■ lung biopsy

2

■ respiratory secretions

3

■ pleural fluid

Species: _______________________________________________

2

■ DFA Positive:
Mo.

If Yes,
Date:

Day

Year

Site: 1

■ lung biopsy

2

■ respiratory secretions

3

4

■ Fourfold rise in antibody titer:

■ pleural fluid

Date:

If Yes,
Mo.

Day

■ blood

8

■ Other: (Specify) __________________________

Serogroup: _____________________________________________

Species: _______________________________________________

3

4

4

■ blood

8

■ Other: (Specify) __________________________

Serogroup: _____________________________________________

List Species and Serogroup in assay used:
Year

Initial (acute) titer 1: ________________

Species: _______________________________

Serogroup: __________________________

Convalescent titer 1: ________________

Species: _______________________________

Serogroup: __________________________

■ Urine Antigen Positive:
Date:

Mo.

Day

If Yes,
Year

– INTERVIEWER IDENTIFICATION –
Interviewer’s Name:

Affiliation:

Telephone No.:

Date of Interview:
Mo.

Day

Year

__ __ __ - __ __ __ - __ __ __ __
– CDC USE ONLY –
Local Health Dept. Please submit this document to:

Check the appropriate answer:

State/DHD/SSS via your CD reporting clerk

State Health Dept. Return completed form to:
Respiratory Diseases Branch, Mailstop C23
National Center for Infectious Diseases
Centers for Disease Control and Prevention
1600 Clifton Rd. NE
Atlanta, GA 30333

Serogroup: __________________________________

1

■

L. pneumophila

6

■

L. feeleii

2

■

L. bozemanii

7

■

L. Iongbeachae

3

■

L. dumoffii

8

■

Mixed: (specify)___________________________________

4

■

L. gormanii

88

■

Other: (specify)___________________________________

5

■

L. micdadei

99

■

Unk

– COMMENTS –

CDC 52.56 Rev. 02/2003

– LEGIONELLOSIS CASE REPORT –

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