FluSurv-NET Influenza Hospital Surveillance Project

Case ID:

1 4 1 5

Form Approved
OMB No. 0920-0987
.
08/31/2016

2014-15 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form
A. Patient Data – THIS INFORMATION IS NOT SENT TO CDC
Last Name:

First Name:

Phone Number 1:

Phone Number 2:

Street Address:

City:

Zip:

Chart Number:

Census Tract:

Address Type:

Emergency Contact 1:

Emergency Contact Phone:

PCP Name 1:
PCP Name 2:
Site Use 1:

PCP Phone 1:
PCP Phone 2:
Site Use 2:

PCP Fax 1:
PCP Fax 2:
Site Use 3:

B. Reporter Information – THIS INFORMATION IS NOT SENT TO CDC
2. Date Reported:

1. Reporter Name: _________________________________________

____/ ____/ ____

C. Enrollment Information
1. Case Classification:
 Prospective Surveillance

2. Admission Type:
3. County:
4. State:
 Hospitalization
 Observation Only
 Years
 Days (if < 1 month)
 Male
5. Case Type:
6. Date of Birth: 7. Age:
8. Sex:
 Pediatric
 Adult
____/ ____/ ____ _________
 Months (if < 1 yr)
 Female
 Black or African American
 Asian/Pacific Islander
9.Race:  White
10. Ethnicity:  Hispanic or Latino
 American Indian or Alaska Native
 Multiracial  Not specified
 Non-Hispanic or Latino
 Not Specified
11. Hospital ID Where
11a. Admission Date:
11b. Discharge Date:
___________
_____/ _____/ _____
____/ _____/ _____
Patient Treated:
 Yes
 No
 Unknown
12. Was patient transferred from another hospital?
12a. Transfer Hospital ID:
_____________
 Discharge Audit

_____/ _____/ _____

12b. Transfer Hospital Admission Date:

13. Where did patient reside at the time of hospitalization?
 Private residence

 Alcohol/Drug Abuse Treatment

 Homeless/Shelter

 Hospitalized at birth

 Nursing home

 Rehabilitation facility

12c. Transfer Date:

_____/ _____/ _____

Indicate TYPE of residence.
 Assisted living/Residential care

 Jail/Prison

 Group home/Retirement home

 LTACH/Transitional Care (TCU)

 Hospice

Unknown

 Mental Hospital

 Other, specify: ___________________

13a. If resident of a facility, indicate NAME of facility: ____________________________________________________________

D. Influenza Testing Results
1. Test 1:
1a. Result:

 Rapid

 Molecular Assay

2a. Result:

3a. Result:

4a. Result:

 Method Unknown/Note Only

 Flu A/B (Not Distinguished)

 2009 H1N1

 H1, Unspecified

 H3

 Flu A, Unsubtypable

 Flu B, Victoria

 Negative

 Unknown Type

 Other, specify: ___________________________

 Rapid

1c. Testing facility ID: __________________

 Molecular Assay

 Viral Culture

 Serology

 Flu B, Yamagata

1d. Specimen ID: _______________________

 Fluorescent Antibody

 Method Unknown/Note Only

 Flu A (no subtype)

 Flu B (no genotype)

 Flu A & B

 Flu A/B (Not Distinguished)

 2009 H1N1

 H1, Unspecified

 H3

 Flu A, Unsubtypable

 Flu B, Victoria

 Negative

 Unknown Type

 Other, specify: ___________________________

 Rapid

2c. Testing facility ID: __________________

 Molecular Assay

 Viral Culture

 Serology

 Flu B, Yamagata

2d. Specimen ID: _______________________

 Fluorescent Antibody

 Method Unknown/Note Only

 Flu A (no subtype)

 Flu B (no genotype)

 Flu A & B

 Flu A/B (Not Distinguished)

 2009 H1N1

 H1, Unspecified

 H3

 Flu A, Unsubtypable

 Flu B, Victoria

 Negative

 Unknown Type

 Other, specify: ___________________________

3b. Specimen collection date: ___/___/ ___
4. Test 4:

 Fluorescent Antibody

 Flu A & B

2b. Specimen collection date: __/___/ ___
3. Test 3:

 Serology

 Flu B (no genotype)

1b. Specimen collection date: __/___/ ___
2. Test 2:

 Viral Culture

 Flu A (no subtype)

 Rapid

3c. Testing facility ID: __________________

 Molecular Assay

 Viral Culture

 Serology

 Flu B, Yamagata

3d. Specimen ID: _______________________

 Fluorescent Antibody

 Method Unknown/Note Only

 Flu A (no subtype)

 Flu B (no genotype)

 Flu A & B

 Flu A/B (Not Distinguished)

 2009 H1N1

 H1, Unspecified

 H3

 Flu A, Unsubtypable

 Flu B, Yamagata

 Flu B, Victoria
 Negative
 Unknown Type
 Other, specify: ___________________________
4b. Specimen collection date: ___/___/ ___
4c. Testing facility ID: __________________
4d. Specimen ID: _______________________

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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 (0920-0987).

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Case ID:

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2014-15 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form
E. Admission and Patient History
1. Was patient discharged from any hospital within one week prior to the current admission date?

 Yes

 No

 Unknown

2. Acute signs/symptoms at admission [within 2 weeks prior to positive flu test]:
(Write Y or N/Unk next to signs/symptoms)
___ Altered mental status/confusion
___ Cough*
___ Myalgia/muscle aches
___ Shortness of breath/resp distress*
___ Chest pain
___ Diarrhea
___ Nausea/vomiting
___ Sore throat*
___ Congested/runny nose*
___ Fever/chills
___ Rash
___ Wheezing*
___ Conjunctivitis/pink eye
___ Headache
___ Seizures
___ Other, non-respiratory
3. Date of onset of acute respiratory symptoms [within 2 weeks prior to positive flu test]:
4. Date of onset of acute condition resulting in current hospitalization:
 Unk
 In
 Cm
 Unk
5. BMI:
6. Height:
8. Smoker:

 Current

 Former

 No/Unknown

9. Alcohol abuse:

7. Weight:
 Current

10. Did patient have any of the following pre-existing medical conditions? Check all that apply.
10a Asthma/Reactive Airway Disease

 Yes

 No/Unknown

 Yes  No/Unknown
10b. Chronic Lung Disease
 Cystic fibrosis
 Emphysema/COPD
 Other, specify________________________________________
 Yes  No/Unknown
10c. Chronic Metabolic Disease
 Diabetes
 Thyroid dysfunction
 Other, specify________________________________________
10d. Blood disorders/Hemoglobinopathy  Yes  No/Unknown
 Sickle cell disease
 Splenectomy/Asplenia
 Thrombocytopenia
 Other, specify ________________________________________
 Yes  No/Unknown
10e. Cardiovascular Disease
 Atherosclerotic cardiovascular disease (ASCVD)
 Cerebral vascular incident/Stroke
 Congenital heart disease
 Coronary artery disease (CAD)
 Heart failure/CHF
 Other, specify _______________________________________
 Yes  No/Unknown
10f. Neuromuscular disorder
 Duchenne muscular dystrophy
 Muscular dystrophy
 Multiple sclerosis
 Mitochondrial disorder
 Myasthenia gravis
 Other, specify: _____________________________________
 Yes  No/Unknown
10g. Neurologic disorder
 Cerebral palsy
 Cognitive dysfunction
 Dementia
 Developmental delay
 Down syndrome
 Plegias/Paralysis
 Seizure/Seizure disorder
 Other, specify: _____________________________________

 Unknown
 Unknown
 Lbs
 Kg

____/ ____/ ____
____/ ____/ ____
 Former
 Yes

10h History of Guillain-Barré Syndrome

 Unk

 No/Unknown

 No
 Yes

 Unknown
 No/Unknown

 Yes  No/Unknown
10i. Immunocompromised Condition
 AIDS or CD4 count < 200
 Cancer: current/in treatment or diagnosed in last 12 months
 Complement deficiency
 HIV Infection
 Immunoglobulin deficiency
 Immunosuppressive therapy
 Organ transplant
 Stem cell transplant (e.g., bone marrow transplant)
 Steroid therapy (taken within 2 weeks of admission)
 Other, specify________________________________________
 Yes  No/Unknown
10j. Renal Disease
 Chronic kidney disease/chronic renal insufficiency
 End stage renal disease/Dialysis
 Glomerulonephritis
 Nephrotic syndrome
 Other, specify _______________________________
 Yes  No/Unknown
10k. Other
 Intravenous drug use
 Liver disease (e.g., cirrhosis, chronic hepatitis, hepatitis C)
 Systemic lupus erythematosus/SLE/Lupus
 Morbidly obese (ADULTS ONLY)
 Obese
 Pregnant
 If pregnant, specify gestational age in weeks: ____________
 Unknown gestational age
 Post-partum (two weeks or less)
 Other, specify ________________________________________

10l PEDIATRIC CASES ONLY
 Yes  No/Unknown
Abnormality of upper airway
 Yes  No/Unknown
History of febrile seizures
 Yes  No/Unknown
Long-term aspirin therapy
 Yes  No/Unknown
Premature
(gestation age < 37 weeks at birth for patients < 2yrs)
If yes, specify gestational age at birth in weeks: _______________
 Unknown gestational age at birth

*These are considered acute respiratory symptoms

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2014-15 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form
F. Intensive Care Unit and Interventions
1. Was the patient admitted to an intensive care unit (ICU)?
1a. Number of ICU Admissions: _________
 Unknown
 Unknown
1b. Date of first ICU Admission: ____/____/____

 Yes
1c. Date of first ICU Discharge:

2. Did patient receive mechanical ventilation?
3. Did patient receive extracorporeal membrane oxygenation (ECMO or ‘on bypass’)?

 No

___/____/____
 Yes  No
 Yes  No

 Unknown
 Unknown
 Unknown
 Unknown

G. Bacterial Pathogens – Sterile or respiratory site only
 Yes  No
 Unknown
1. Were any bacterial culture tests performed with a collection date within three days of admission?
 Yes  No
 Unknown
2. If yes, was there a positive culture for a bacterial pathogen?
____/ ____/ ____
3a. If yes, specify Pathogen 1: ___________________________________________ 3b. Date of culture:
 Blood
 Cerebrospinal fluid (CSF)
 Bronchoalveolar lavage (BAL)
3c. Site where pathogen identified:

 Pleural fluid
 Endotracheal aspirate
 Other, specify: _________________
Sputum
 Methicillin resistant (MRSA)
 Methicillin sensitive (MSSA)
 Sensitivity unknown
3d. If Staphylococcus aureus, specify:
 Yes
 No
 Unknown
3e. If Haemophilus influenzae, specify if type B:
B
C
Y
 Other, specify: ____________  Unknown
3f. If Neisseria meningitidis, specify serogroup:
____/ ____/ ____
4a. Specify Pathogen 2: ________________________________________________ 4b. Date of culture:
 Blood
 Cerebrospinal fluid (CSF)
 Bronchoalveolar lavage (BAL)
4c. Site where pathogen identified:
 Sputum
 Pleural fluid
 Endotracheal aspirate
 Other, specify: ______________________
 Methicillin resistant (MRSA)
 Methicillin sensitive (MSSA)
 Sensitivity unknown
4d. If Staphylococcus aureus, specify:
 Yes
 No
 Unknown
4e. If Haemophilus influenzae, specify if type B:
B
C
Y
 Other, specify: ____________  Unknown
4f. If Neisseria meningitidis, specify serogroup:

H. Viral Pathogens
 Yes
1. Was patient tested for any of the following viral respiratory pathogens within 3 days of admission?
1a. Respiratory syncytial virus/RSV
 Yes, positive
 Yes, negative
 Not tested/Unknown
1b. Adenovirus
 Yes, positive
 Yes, negative
 Not tested/Unknown
1c. Parainfluenza 1
 Yes, positive
 Yes, negative
 Not tested/Unknown
1d. Parainfluenza 2
 Yes, positive
 Yes, negative
 Not tested/Unknown
1e. Parainfluenza 3
 Yes, positive
 Yes, negative
 Not tested/Unknown
1f. Parainfluenza 4
 Yes, positive
 Yes, negative
 Not tested/Unknown
1g. Human metapneumovirus
 Yes, positive
 Yes, negative
 Not tested/Unknown
1h. Rhinovirus/Enterovirus
 Yes, positive
 Yes, negative
 Not tested/Unknown
1i.Coronavirus (type):____________  Yes, positive
 Yes, negative
 Not tested/Unknown

 No
 Unknown
Date: ____/____/____
Date: ____/____/____
Date: ____/____/____
Date: ____/____/____
Date: ____/____/____
Date: ____/____/____
Date: ____/____/____
Date: ____/____/____
Date: ____/____/____

I. Influenza Treatment
 Yes  No
 Unknown
1. Did patient receive antiviral medication treatment for influenza during the course of this illness?
 Oseltamivir (Tamiflu)
 Zanamivir (Relenza)
 Other, specify: _______________________________
2a. Treatment 1:
 Amantadine (Symmetrel)
 Rimantadine (Flumadine)
 Unknown
 Intravenous (IV)  Inhaled
 Unknown
2b. Method of Administration:  Oral
2c. Start Date: ___/____/___
2d. End Date: ____/____/____ 2e. Dose: _________________
2f. Frequency: _________________
 Start Date Unknown
 End Date Unknown
 Dose Unknown
 Frequency Unknown
 Oseltamivir (Tamiflu)
 Zanamivir (Relenza)
 Other, specify: _______________________________
3a. Treatment 2:
 Amantadine (Symmetrel)
 Rimantadine (Flumadine)
 Unknown
 Oral
 Intravenous (IV)  Inhaled
 Unknown
3b. Method of Administration:
3c. Start Date: ___/____/___
3d. End Date: ____/____/____ 3e. Dose: _________________
3f. Frequency: _________________
 Start Date Unknown
 End Date Unknown
 Dose Unknown
 Frequency Unknown
 Oseltamivir (Tamiflu)
 Zanamivir (Relenza)
 Other, specify: _______________________________
4a. Treatment 3:
 Amantadine (Symmetrel)
 Rimantadine (Flumadine)
 Unknown
 Oral
 Intravenous (IV)  Inhaled
 Unknown
4b. Method of Administration:
4c. Start Date: ___/____/___
4d. End Date: ____/____/____ 4e. Dose: _________________
4f. Frequency: _________________
 Start Date Unknown
 End Date Unknown
 Dose Unknown
 Frequency Unknown
 Oseltamivir (Tamiflu)
 Zanamivir (Relenza)
 Other, specify: _______________________________
5a. Treatment 4:
 Amantadine (Symmetrel)
 Rimantadine (Flumadine)
 Unknown
 Oral
 Intravenous (IV)  Inhaled
 Unknown
5b. Method of Administration:
5c. Start Date: ___/____/___
5d. End Date: ____/____/____ 5e. Dose: _________________
5f. Frequency: _________________
 Start Date Unknown
 End Date Unknown
 Dose Unknown
 Frequency Unknown
6. Additional Treatment Comments:

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2014-15 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form
J. Chest Radiograph – Based on radiology report only
 Yes
 No
 Unknown
1. Was a chest x-ray taken within 3 days of admission?
 Yes
 No
 Unknown
2. Were any of these chest x-rays abnormal?
____/____/____
2a. Date of first abnormal chest x-ray:
2b. For first abnormal chest x-ray, please check all that apply:
 Report not available
 Consolidation
 Interstitial infiltrate
 Air space density/opacity
 Atelectasis
 Pleural effusion/empyema
 Bronchopneumonia/pneumonia
 Cavitation
 Lobar infiltrate
 Cannot rule out pneumonia
 ARDS (acute respiratory distress syndrome)
 Other

K. Discharge Summary
1. Did the patient have any of the following diagnoses at discharge (check all that apply)?
Pneumonia
Guillain-Barré
syndrome
Acute encephalopathy/
encephalitis
Seizures

 Yes

 No

 Unknown

Stroke (CVI)

 Yes

 No

 Unknown

 Yes

 No

 Unknown

Acute myocarditis

 Yes

 No

 Unknown

 Yes

 No

 Unknown

 Yes

 No

 Unknown

 Yes

 No

 Unknown

Acute respiratory distress syndrome
(ARDS)
Bronchiolitis

 Yes

 No

 Unknown

Reye’s syndrome

 Yes

 No

 Unknown

Hemophagocytic syndrome

 Yes

 No

 Unknown

 Alive
 Deceased
 Unknown
2. What was the outcome of the patient?
2a. If discharged alive, please indicate to where:
 Private residence
 Alcohol/Drug Abuse Treatment
 Assisted living/Residential Care  Group home/Retirement home
 Home with Services
 Homeless/Shelter
 Jail/Prison
 LTACH/Transitional Care (TCU)
 Mental Hospital
 Nursing home
 Rehabilitation Facility
 Hospice
 Unknown
 Other, specify: ________________
 Still pregnant  No longer pregnant
 Unknown
3. If patient was pregnant on admission, indicate pregnancy status atdischarge:
3a. If patient was pregnant on admission but no longer pregnant at discharge, indicate pregnancy outcome at discharge:
 Miscarriage
 Ill newborn
 Newborn died
 Healthy newborn
 Abortion
 Unknown
4. Additional notes regarding discharge: _____________________________________________________________________________________

L. ICD-9 or ICD-10 Discharge Diagnoses – To be recorded in order of appearance
Version:

 ICD-9

 ICD-10

1.

4.

7.

2.
3.

5.
6.

8.
9.

M. Vaccination History
Specify vaccination status and date(s) by source:
 Yes, full date known
1. Medical Chart:
1) ___/___/___
1a. If yes, specify dosage date information:
1b. If patient < 9 yrs, specify vaccine type:  Injected Vaccine
 Yes, full date known
2.Vaccine Registry:
1) ___/___/___
2a. If yes, specify dosage date information:
 Injected Vaccine
2b. If patient < 9 yrs, specify vaccine type:
3. Primary Care Provider
 Yes, full date known
/ Long-term Care Facility:
1) ___/___/___
3a. If yes, specify dosage date information:
 Injected Vaccine
3b. If patient < 9 yrs, specify vaccine type:
4. Interview:
 Yes, full date known
 Patient  Proxy
1) ___/___/___
4a. If yes, specify dosage date information:
 Injected Vaccine
4b. If patient < 9 yrs, specify vaccine type:

 Yes, specific date unknown
 No
 Unknown
 Date Unknown
2) (Pediatrics Only) ___/___/___
 Nasal Spray/FluMist
 Combination of both
 Yes, specific date unknown
 No
 Unknown
 Date Unknown
2) (Pediatrics Only) ___/___/___
 Nasal Spray/FluMist
 Combination of both

 Not Checked
 Date Unknown
 Unknown type
 Not Checked
 Date Unknown
 Unknown type

 Yes, specific date unknown

 Not Checked

 No

 Unknown

 Date Unknown
2) (Pediatrics Only) ___/___/___
 Nasal Spray/FluMist
 Combination of both

 Date Unknown
 Unknown type

 Yes, specific date unknown

 Not Checked

 No

 Unknown

 Date Unknown
2) (Pediatrics Only) ___/___/___
 Date Unknown
 Nasal Spray/FluMist
 Combination of both
 Unknown type
 Yes
 No
 Unknown
5. If patient < 9 yrs, did patient receive any seasonal influenza vaccine in previous seasons?

N. Miscellaneous
1. Additional Comments:

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