Document
CDC Rev 07-2015 2015-16 FluSurv-NET Influenza Hospitalization Surveillan
ICR 201801-0920-004 · OMB 0920-0978 · Object 80127201.
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0978 can be found here:
Document [pdf]
Download: pdf | txt
2015-16 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION ATLANTA, GA 30333 1 Case ID: 5 1 Form Approved OMB No. 0920-0978 6 A. Patient Data – THIS INFORMATION IS NOT SENT TO CDC Chart Number: First Name: Last Name: Address: Census Tract: Address Type: (Number, Street, Apt. No.) (City) (State) Phone No.1: (Zip Code) Phone No.2: Emergency Contact 1: Emergency Contact Phone: PCP Name 1: PCP Phone 1: PCP Fax 1: PCP Name 2: PCP Phone 2: PCP Fax 2: Site Use 1: Site Use 2: Site Use 3: B. Reporter Information – THIS INFORMATION IS NOT SENT TO CDC 1. Reporter Name: / 2. Date Reported: / C. Enrollment Information 1. Case Classification: 2. Admission Type: Prospective Surveillance Discharge Audit 6. Date of Birth: 7. Age: / Years / 3. County: Hospitalization 8. Sex: Days (if < 1 month) Months (if < 1 yr) 10. Ethnicity: Non-Hispanic or Latino Not Specified Pediatric 9. Race: Adult White American Indian or Alaska Native Black or African American Multiracial Male Asian/Pacific Islander Not specified 12. Was patient transferred from another hospital? 11a. Admission Date: / / 12a. Transfer Hospital ID: 11b. Discharge Date: / / 12c. Transfer Date: 13. Where did patient reside at the time of hospitalization? 5. Case Type: Female 11. Hospital ID Where Patient Treated: Hispanic or Latino 4. State: Observation Only 12b. Transfer Hospital Admission Date: / / / Yes No Unknown / (Indicate TYPE of residence.) Private residence Hospitalized at birth Assisted living/Residential care Unknown Homeless/Shelter Rehabilitation facility LTACH/Transitional Care (TCU) Other, specify: Nursing home Jail/Prison Group home/Retirement home Alcohol/Drug Abuse Treatment Hospice Mental Hospital 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 Flu A, Unsubtypable Flu B, Yamagata Unknown Type H1, Unspecified Flu B (no genotype) Flu A & B Negative Rapid / / Molecular Assay 1c. Testing facility ID: Viral Culture Serology Fluorescent Antibody Method Unknown/Note Only H3 Flu B, Victoria Flu A/B (Not Distinguished) 2009 H1N1 Flu A, Unsubtypable Flu B, Yamagata Unknown Type H1, Unspecified Flu B (no genotype) Flu A & B Negative Rapid / / Molecular Assay 2c. Testing facility ID: Viral Culture Serology Fluorescent Antibody Method Unknown/Note Only H3 Flu B, Victoria Flu A/B (Not Distinguished) 2009 H1N1 Flu A, Unsubtypable Flu B, Yamagata Unknown Type H1, Unspecified Flu B (no genotype) Flu A & B Negative / / Molecular Assay 3c. Testing facility ID: Viral Culture Serology Method Unknown/Note Only H3 Flu B, Victoria Flu A/B (Not Distinguished) 2009 H1N1 Flu A, Unsubtypable Flu B, Yamagata Unknown Type H1, Unspecified Flu B (no genotype) Flu A & B Negative / / Other, specify: 3d. Specimen ID: Fluorescent Antibody Flu A (no subtype) 4b. Specimen collection date: Other, specify: 2d. Specimen ID: Flu A (no subtype) Rapid Other, specify: 1d. Specimen ID: Flu A (no subtype) 3b. Specimen collection date: 4. Test 4: Fluorescent Antibody Flu B, Victoria 2b. Specimen collection date: 3. Test 3: Serology H3 1b. Specimen collection date: 2. Test 2: Viral Culture Flu A (no subtype) 4c. Testing facility ID: Other, specify: 4d. Specimen ID: Public reporting burden of this collection of information is estimated to average 17 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). Page 1 of 4 2015-16 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form 1 Case ID: 5 1 6 E. Admission and Patient History 1. Was patient discharged from any hospital within one week prior to the current admission date? 2. Acute signs/symptoms at admission [within 2 weeks prior to positive flu test]: Yes No Unknown (Write Y or N/Unk next to signs/symptoms) Altered mental status/confusion Cough* Headache Seizures Wheezing* Chest pain Diarrhea Myalgia/muscle aches Shortness of breath/resp distress* Other, non-respiratory Congested/runny nose* Fatigue/weakness Nausea/vomiting Sore throat* Conjunctivitis/pink eye Fever/chills Rash URI/ILI* / / 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: 5. BMI: 6. Height: Unknown In / / 7. Weight: Cm Kg Yes 10b. Chronic Lung Disease? Yes 9. Alcohol abuse: Current Former No/Unknown Unknown 10. Did patient have any of the following pre-existing medical conditions? Check all that apply. 10a. Asthma/Reactive Airway Disease? Unknown 8. Smoker: Lbs Unknown Unknown Yes No Current Former No/Unknown Unknown No/Unknown 10h History of Guillain-Barré Syndrome Yes No/Unknown No/Unknown 10i. Immunocompromised Condition Yes No/Unknown Cystic fibrosis AIDS or CD4 count < 200 Emphysema/COPD Cancer: current/in treatment or diagnosed in last 12 months Other, specify: Complement deficiency 10c. Chronic Metabolic Disease Yes HIV Infection No/Unknown Diabetes Mellitus Immunoglobulin deficiency Thyroid dysfunction Immunosuppressive therapy Organ transplant Other, specify: 10d. Blood disorders/Hemoglobinopathy Yes Stem cell transplant (e.g., bone marrow transplant) No/Unknown Steroid therapy (taken within 2 weeks of admission) Sickle cell disease Other, specify: Splenectomy/Asplenia 10j. Renal Disease Thrombocytopenia Yes Chronic kidney disease/chronic renal insufficiency Other, specify: 10e. Cardiovascular Disease Yes Atherosclerotic cardiovascular disease (ASCVD) No/Unknown End stage renal disease/Dialysis No/Unknown Glomerulonephritis Nephrotic syndrome Atrial Fibrillation Other, specify: Cerebral vascular incident/Stroke 10k. Other Congenital heart disease Yes No/Unknown Coronary artery disease (CAD) Intravenous drug use Heart failure/CHF Liver disease (e.g., cirrhosis, chronic hepatitis, hepatitis C) Other, specify: Systemic lupus erythematosus/SLE/Lupus Morbidly obese (ADULTS ONLY) 10f. Neuromuscular disorder Yes No/Unknown Obese Duchenne muscular dystrophy Pregnant Muscular dystrophy If pregnant, specify gestational age in weeks: Multiple sclerosis Unknown gestational age Mitochondrial disorder Post-partum (two weeks or less) Myasthenia gravis Other, specify: Other, specify: 10g. Neurologic disorder Yes No/Unknown Cerebral palsy 10l. PEDIATRIC CASES ONLY Cognitive dysfunction Abnormality of upper airway History of febrile seizures Long-term aspirin therapy Premature Dementia Developmental delay Down syndrome Yes No/Unknown Yes No/Unknown Yes No/Unknown Yes (gestation age < 37 weeks at birth for patients < 2yrs) Plegias/Paralysis Seizure/Seizure disorder No/Unknown If yes, specify gestational age at birth in weeks: Other, specify: Unknown gestational age at birth *These are considered acute respiratory symptoms F. Intensive Care Unit and Interventions 1. Was the patient admitted to an intensive care unit (ICU)? 1a. Number of ICU admissions: 1b. Date of first ICU Admission: 1c. Date of first ICU Discharge: Yes No Unknown / / / / 2. Did patient receive mechanical ventilation? Yes Unknown No Unknown 3. Did patient receive extracorporeal membrane oxygenation (ECMO or ‘on bypass’)? Unknown Unknown Yes Page 2 of 4 No Unknown 2015-16 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form 1 Case ID: 5 1 6 G. Bacterial Pathogens – Sterile or respiratory site only 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? Yes No Unknown 3a. If yes, specify Pathogen 1: 3c. Site where pathogen identified: / 3b. Date of culture: / Blood Cerebrospinal fluid (CSF) Bronchoalveolar lavage (BAL) Pleural fluid Sputum Endotracheal aspirate Other, specify: 3d. If Staphylococcus aureus, specify: Methicillin resistant (MRSA) 3f. If Neisseria meningitidis, specify serogroup: Methicillin sensitive (MSSA) B Sensitivity unknown No 4c. Site where pathogen identified: / 4b. Date of culture: / Blood Cerebrospinal fluid (CSF) Bronchoalveolar lavage (BAL) Pleural fluid Sputum Endotracheal aspirate Other, specify: 4d. If Staphylococcus aureus, specify: Methicillin resistant (MRSA) 4f. If Neisseria meningitidis, specify serogroup: Methicillin sensitive (MSSA) B Sensitivity unknown C Y Other, specify: 4e. If Haemophilus influenzae, specify if type B: No Unknown Unknown 4a. If yes, specify Pathogen 2: Yes Y Other, specify: 3e. If Haemophilus influenzae, specify if type B: Yes C Unknown Unknown H. Viral Pathogens 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 Date: 1b. Adenovirus Yes, positive Yes, negative Not tested/Unknown Date: 1c. Parainfluenza 1 Yes, positive Yes, negative Not tested/Unknown Date: 1d. Parainfluenza 2 Yes, positive Yes, negative Not tested/Unknown Date: 1e. Parainfluenza 3 Yes, positive Yes, negative Not tested/Unknown Date: 1f. Parainfluenza 4 Yes, positive Yes, negative Not tested/Unknown Date: 1g. Human metapneumovirus Yes, positive Yes, negative Not tested/Unknown Date: 1h. Rhinovirus/Enterovirus Yes, positive Yes, negative Not tested/Unknown Date: 1i. Coronavirus (type): Yes, positive Yes, negative Not tested/Unknown Date: Yes No / / / / / / / / / Unknown / / / / / / / / / I. Influenza Treatment 1. Did patient receive antiviral medication treatment for influenza during the course of this illness? 2a. Treatment 1: Zanamivir (Relenza) Other, specify: Amantadine (Symmetrel) Rimantadine (Flumadine) Unknown 2b. Method of Administration: 2c. Start Date: / Oral / Intravenous (IV) Zanamivir (Relenza) Amantadine (Symmetrel) Rimantadine (Flumadine) / Oral / Intravenous (IV) Rimantadine (Flumadine) / / Intravenous (IV) 3e. Dose: 3f. Frequency: Unknown Inhaled / Unknown 4e. Dose: End Date Unknown 4f. Frequency: Dose Unknown Zanamivir (Relenza) Other, specify: Amantadine (Symmetrel) Rimantadine (Flumadine) Unknown / Oral / Start Date Unknown Intravenous (IV) 5d. End Date: / Frequency Unknown Other, specify: Oseltamivir (Tamiflu) 5b. Method of Administration: 5c. Start Date: / 4d. End Date: Frequency Unknown Unknown Dose Unknown Zanamivir (Relenza) Start Date Unknown 5a. Treatment 4: / Amantadine (Symmetrel) Oral 2f. Frequency: Unknown Inhaled Oseltamivir (Tamiflu) Unknown Other, specify: End Date Unknown 4b. Method of Administration: 4c. Start Date: / 3d. End Date: No Unknown 2e. Dose: Dose Unknown Oseltamivir (Tamiflu) Start Date Unknown 4a. Treatment 3: Inhaled / End Date Unknown 3b. Method of Administration: 3c. Start Date: / 2d. End Date: Start Date Unknown 3a. Treatment 2: Yes Oseltamivir (Tamiflu) Inhaled / End Date Unknown Unknown 5e. Dose: Dose Unknown 6. Additional Treatment Comments: Page 3 of 4 Frequency Unknown 5f. Frequency: Frequency Unknown 2015-16 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form 1 Case ID: 5 1 6 J. Chest Radiograph – Based on radiology report only 1. Was a chest x-ray taken within 3 days of admission? 2. Were any of these chest x-rays abnormal? Yes No No Unknown 2b. For first abnormal chest x-ray, please check all that apply: Unknown 2a. Date of first abnormal chest x-ray: / Yes / 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 Yes No Unknown Stroke (CVI) Yes No Unknown Guillain-Barré syndrome Yes No Unknown Acute myocarditis Yes No Unknown Acute encephalopathy/ encephalitis Yes No Unknown Acute respiratory distress syndrome (ARDS) Yes No Unknown Seizures Yes No Unknown Bronchiolitis Yes No Unknown Reye’s syndrome Yes No Unknown Hemophagocytic syndrome Yes No Unknown 2. What was the outcome of the patient? 2a. If discharged alive, please indicate to where: Alive Deceased Unknown Private residence Rehabilitation Facility Group home/Retirement home Homeless/Shelter Jail/Prison Mental Hospital Nursing home Hospice Unknown Alcohol/Drug Abuse Treatment Assisted living/Residential care Other, specify: Home with services LTACH/Transitional Care (TCU) 3. If patient was pregnant on admission, indicate pregnancy status at discharge: Still pregnant No longer pregnant Unknown 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. 5. 8. 3. 6. 9. M. Vaccination History Specify vaccination status and date(s) by source: 1. Medical Chart: Yes, full date known 1a. If yes, specify dosage date information: 1) / / 1b. If patient < 9 yrs, specify vaccine type: Injected Vaccine 2.Vaccine Registry: Yes, full date known 2a. If yes, specify dosage date information: 1) 2b. If patient < 9 yrs, specify vaccine type: / / Injected Vaccine Injected Vaccine 4. Interview: Yes, full date known Proxy 4b. If patient < 9 yrs, specify vaccine type: / Injected Vaccine Date Unknown Date Unknown / Date Unknown 5. If patient < 9 yrs, did patient receive any seasonal influenza vaccine in previous seasons? No 2) (Pediatrics Only) / No 2) (Pediatrics Only) No Combination of both Yes No / Unknown / Date Unknown Not Checked / Date Unknown Unknown type Unknown / Combination of both 2) (Pediatrics Only) Not Checked Unknown type Combination of both Yes, specific date unknown Nasal Spray/FluMist Unknown Combination of both Yes, specific date unknown Nasal Spray/FluMist No 2) (Pediatrics Only) Yes, specific date unknown Nasal Spray/FluMist 3b. If patient < 9 yrs, specify vaccine type: Patient Date Unknown Nasal Spray/FluMist 3. Primary Care Provider / Yes, full date known Long-term Care Facility: 3a. If yes, specify dosage date information: 1) / / 4a. If yes, specify dosage date information: 1) Yes, specific date unknown Not Checked / Date Unknown Unknown type Unknown / Not Checked / Date Unknown Unknown type Unknown N. Miscellaneous 1. Additional Comments: CDC Rev. 07-2015 Page 4 of 4 CS255957
| File Type | application/pdf |
| File Title | CDC Rev 07-2015 2015-16 FluSurv-NET Influenza Hospitalization Surveillan |
| File Modified | 2015-08-12 |
| File Created | 2015-08-12 |