Document
Form 0920-0978 2017-18 FluSurv-NET Influenza Hospitalization Surveillan
ICR 201803-0920-010 · OMB 0920-0978 · Object 82267001.
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0978 can be found here:
Document [pdf]
Download: pdf | txt
2017-18 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: 7 1 Form Approved OMB No. 0920-0978 8 A. Patient Data – THIS INFORMATION IS NOT SENT TO CDC First Name: Last Name: Address: Middle Name: Address Type: (Number, Street, Apt. No.) (City) (State) Phone No.2: Chart No. : Phone No. 1: (Zip Code) Emergency Contact: Emergency Contact Phone: No PCP PCP Clinic Name 1: PCP Phone 1: PCP Fax 1: PCP Clinic Name 2: PCP Phone 2: PCP Fax 2: Site Use 2: Site Use 1: Site Use 3: B. Abstractor Information – THIS INFORMATION IS NOT SENT TO CDC 1. Abstractor Name: 2. Date of Abstraction: C. Enrollment Information 1. Case Classification: Prospective Surveillance 6. Date of Birth: / Discharge Audit 7. Age: Years Hispanic or Latino 3. County: (if < 1 month) 9. Race: Male Female (if < 1 yr) / 4. State: 5. Case Type: Pediatric Observation Only 8. Sex: Days Months / 10. Ethnicity: 2. Admission Type: Hospitalization / White Black or African American Asian/Pacific Islander American Indian or Alaska Native Multiracial Not specified 12. Was patient discharged from any hospital within 1 week prior to the current admission date? Yes No Unknown 11. Hospital ID Where Patient Treated: Non-Hispanic or Latino 11a. Admission Date: / / 13. Was patient transferred from another hospital? Not Specified / / 13a. Transfer Hospital ID: 11b. Discharge Date: Adult 14. Where did patient reside at the time of hospitalization? (Indicate TYPE of residence.) Private residence Hospice Assisted living/Residential care Homeless/Shelter LTACH Nursing home/Skilled Nursing Facility Group home/Retirement Alcohol/Drug Abuse Treatment Mental Hospital Hospitalized at birth Unknown Rehabilitation facility Other long term care facility Jail/Prison / 15. Type of Insurance: 14a. If resident of a facility, indicate NAME of facility: Unknown / / (Check all that apply): Private Medicare Medicaid/state assistance program Military Indian Health Service Other, specify: No / 13b. Transfer Hospital Admission Date: 13c. Transfer Date: Yes Incarcerated Uninsured Unknown Other, specify: D. Influenza Testing Results (can add up to 4 test results in database) 1. Test 1: 1a. Result: Rapid Antigen Molecular Assay / 1b. Specimen collection date: 2. Test 2: 2a. Result: Rapid Antigen 3a. Result: H1, Seasonal H1 H3 Flu A (no subtype) 2009 H1N1 H1, Unspecified Rapid Antigen / / Molecular Assay H1, Seasonal H1 H3 Flu A (no subtype) 2009 H1N1 H1, Unspecified 3b. Specimen collection date: / Molecular Assay 2b. Specimen collection date: 3. Test 3: H1, Seasonal H1 H3 Flu A (no subtype) 2009 H1N1 H1, Unspecified / / Rapid Molecular Assay Flu A, Unsubtypable Flu B (no lineage) Flu B, Victoria Viral Culture Flu B, Yamagata Flu A & B Flu A/B (Not Distinguished) 1c. Testing facility ID: Rapid Molecular Assay Flu A, Unsubtypable Flu B (no lineage) Flu B, Victoria Flu A, Unsubtypable Flu B (no lineage) Flu B, Victoria Fluorescent Antibody Unknown Type Negative H3N2v Method Unknown Other, specify: 1d. Specimen ID: Viral Culture Serology Flu B, Yamagata Flu A & B Flu A/B (Not Distinguished) 2c. Testing facility ID: Rapid Molecular Assay Serology Fluorescent Antibody Unknown Type Negative H3N2v Method Unknown Other, specify: 2d. Specimen ID: Viral Culture Serology Flu B, Yamagata Flu A & B Flu A/B (Not Distinguished) 3c. Testing facility ID: Fluorescent Antibody Unknown Type Negative H3N2v Method Unknown Other, specify: 3d. Specimen ID: Public reporting burden of this collection of information is estimated to average 25 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 2017-18 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form 1 Case ID: 7 1 8 E. Admission and Patient History / 1. Date of onset of acute condition resulting in current hospitalization: / 2. Acute signs/symptoms present at admission (began or worsened within 2 weeks prior to admission): Non-respiratory symptoms Fatigue/weakness Fever/chills Headache Myalgia/muscle aches Nausea/vomiting Rash Seizures Other, non-respiratory / 3. Date of onset of acute respiratory symptoms (within 2 weeks before a positive flu test): 6. Weight: 5. Height: Unk In Cm Lbs Unk Kg Unk 7. Smoker (tobacco): Former Current Opioids Other, specify: No/Unknown 11b. Chronic Lung Disease Yes No/Unknown Yes No/Unknown Yes No/Unknown Yes No/Unknown Active Tuberculosis/TB Cystic fibrosis Emphysema/COPD Chronic bronchitis Chronic respiratory failure Other, specify: 11c. Chronic Metabolic Disease Diabetes Mellitus Thyroid dysfunction Other, specify: 11d. Blood disorders/Hemoglobinopathy Aplastic anemia Sickle cell disease Splenectomy/Asplenia Other, specify: 11e. Cardiovascular Disease Aortic aneurysm Aortic stenosis Atrial Fibrillation Cardiomyopathy Atherosclerotic cardiovascular disease (ASCVD) Cerebral vascular incident/Stroke Congenital heart disease Coronary artery disease (CAD) Ischemic cardiomyopathy Non-ischemic cardiomyopathy Heart failure/CHF Other, specify: 11f. Neuromuscular disorder Duchenne muscular dystrophy Muscular dystrophy Multiple sclerosis Mitochondrial disorder Myasthenia gravis Parkinson’s disease Other, specify: 11g. Neurologic disorder Yes Yes Unknown 8. Alcohol abuse: Current (check all that apply): 11. Did patient have any of the following pre-existing medical conditions? Check all that apply. Yes / Yes No Marijuana Current Former No/Unk Yes No/Unknown E-cigarettes Other Unknown 11h History of Guillain-Barré Syndrome Yes No/Unknown 11i. Immunocompromised Condition Yes No/Unknown 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: 11j. Renal Disease Yes No/Unknown Chronic kidney disease/chronic renal insufficiency End stage renal disease/Dialysis Glomerulonephritis Nephrotic syndrome Other, specify: 11k. Liver disease Yes No/Unknown Cirrhosis Viral hepatitis (B or C) Other, specify: 11l. Any obesity Obese Morbidly obese (ADULTS ONLY) 11m. Pregnant No/Unknown Not applicable 9. Substance abuse: Former (Optional) 10. Current Non-Tobacco Smoker: Unknown 11a. Asthma/Reactive Airway Disease Congested/runny nose URI/ILI Cough Wheezing Shortness of breath/respiratory distress Sore throat No/Unk No/Unk 9a. Substance Abuse Type (current use only) (check all that apply): IVDU No Signs/Symptoms Respiratory symptoms Altered mental status/confusion Chest pain Conjunctivitis/pink eye Diarrhea 4. BMI: Unknown Yes No/Unknown Yes If pregnant, specify gestational age in weeks: Unknown gestational age 11n. Post-partum (two weeks or less) Yes 11o. Other Yes Systemic lupus erythematosus/SLE/Lupus Other, specify: No/Unknown No/Unknown No/Unknown 11p. 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 No/Unknown Cerebral palsy Cognitive dysfunction Dementia/Alzheimer’s disease Developmental delay Down syndrome Plegias/Paralysis Seizure/Seizure disorder Other, specify: Page 2 of 4 2017-18 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form 1 Case ID: 7 1 8 F. Intensive Care Unit and Interventions (can record up to 3 ICU stays in database) 1. Was the patient admitted to an intensive care unit (ICU)? 1a. Number of ICU Admissions: Yes No Unknown 2. Did patient receive invasive mechanical ventilation? 3. Did patient receive extracorporeal membrane oxygenation (ECMO or ‘on bypass’)? Yes Unknown 1b. Date of first ICU Admission: / / Unknown 1c. Date of first ICU Discharge: / / Unknown Yes No Unknown No Unknown G. Bacterial Pathogens – Sterile or respiratory site only (can record up to 5 pathogens in database) 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: / 3b. Date of culture: 3c. Site where pathogen identified: Blood Bronchoalveolar lavage (BAL) Pleural fluid Other, specify: / 3d. If Staphylococcus aureus, specify: Methicillin resistant (MRSA) 4a. If yes, specify Pathogen 2: Sensitivity unknown 4c. Site where pathogen identified: / 4b. Date of culture: Methicillin sensitive (MSSA) Cerebrospinal fluid (CSF) Sputum Endotracheal aspirate Blood Bronchoalveolar lavage (BAL) Pleural fluid Other, specify: / 4d. If Staphylococcus aureus, specify: Methicillin resistant (MRSA) Methicillin sensitive (MSSA) Cerebrospinal fluid (CSF) Sputum Endotracheal aspirate Sensitivity unknown H. Viral Pathogens 1. Was patient tested for any of the following viral respiratory pathogens within 3 days of admission? Yes No 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: Unknown / / / / / / / / / / / / / / / / / / I. Influenza Treatment (can record up to 4 treatments in database) 1. Did patient receive antiviral medication treatment for influenza during the course of this illness? 2a. Treatment 1: Oseltamivir (Tamiflu) Peramivir (Rapivab) 2b. Method of Administration: 2c. Start Date: / Start Date Unknown 3a. Treatment 2: / Start Date Unknown 4a. Treatment 3: Oral / Oseltamivir (Tamiflu) Peramivir (Rapivab) 4b. Method of Administration: 4c. Start Date: / Oseltamivir (Tamiflu) Peramivir (Rapivab) 3b. Method of Administration: 3c. Start Date: Oral / Start Date Unknown Oral / Zanamivir (Relenza) Other, specify: Intravenous (IV) Unknown Inhaled / End Date Unknown Zanamivir (Relenza) Other, specify: Intravenous (IV) / End Date Unknown Zanamivir (Relenza) Other, specify: Intravenous (IV) 4d. End Date: / End Date Unknown 75 mg 60 mg QD QOD 30 mg 3 mg/kg/dose BID 45 mg Dose Unknown Frequency Unknown 3f. Frequency: 75 mg 60 mg QD QOD 30 mg 3 mg/kg/dose BID 45 mg Dose Unknown Frequency Unknown / 5. Additional Treatment Comments: Page 3 of 4 TID Other 4e. Dose: Unknown TID Other Other Unknown Inhaled 2f. Frequency: 3e. Dose: Unknown / 3d. End Date: Unknown Other Unknown Inhaled No 2e. Dose: Unknown / 2d. End Date: Yes 4f. Frequency: 75 mg 60 mg QD QOD 30 mg 3 mg/kg/dose BID 45 mg Dose Unknown Frequency Unknown Other TID Other 2017-18 FluSurv-NET Influenza Hospitalization Surveillance Project Case Report Form 1 Case ID: 7 1 8 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: Report not available Air space density Air space opacity Bronchopneumonia/pneumonia Unknown 2a. Date of first abnormal chest x-ray: / Yes / Cannot rule out pneumonia Consolidation Cavitation ARDS (acute respiratory distress syndrome) Lung infiltrate Interstitial infiltrate Lobar infiltrate Other K. Discharge Summary 1. Did the patient have any of the following new diagnoses at discharge? (check all that apply) No discharge summary available Bacteremia Yes No/Unk Acute encephalopathy/encephalitis Yes No/Unk Reyes syndrome Yes Bronchiolitis Yes No/Unk Acute Myocardial Infarction Yes No/Unk Rhabdomyolysis Yes Congestive Heart Failure Yes No/Unk Acute Myocarditis Yes No/Unk Pneumonia Yes Sepsis Yes COPD exacerbation Yes No/Unk Acute Renal Failure/Acute Kidney Injury Yes No/Unk Seizures Yes Diabetic Ketoacidosis Yes No/Unk Acute respiratory distress syndrome (ARDS) Yes No/Unk Stroke (CVA) Yes Guillan-Barre syndrome Yes No/Unk Acute respiratory failure Yes No/Unk Hemophagocytic syndrome Yes No/Unk Asthma exacerbation Yes No/Unk 2. What was the outcome 2a. If discharged alive, please indicate to where: of the patient? Private residence Rehabilitation Facility Group home/Retirement home Homeless/Shelter Jail/Prison Mental Hospital Alive Deceased Nursing home /Skilled Nursing Facility Hospice Unknown Unknown Alcohol/Drug Abuse Treatment Assisted living/Residential care Other, specify: Home with services LTACH 3. If patient was pregnant on admission, indicate pregnancy status at discharge: Still pregnant No longer pregnant Unknown No/Unk No/Unk No/Unk No/Unk No/Unk No/Unk 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-10 Discharge Diagnoses – To be recorded in order of appearance ICD codes not available 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: 1b. If patient < 9 yrs, specify vaccine type: / / Injected Vaccine 2.Vaccine Registry: Yes, full date known 2a. If yes, specify dosage date information: / 2b. If patient < 9 yrs, specify vaccine type: Injected Vaccine 3. Primary Care Provider /LTCF: Yes, full date known 3a. If yes, specify dosage date information: / 3b. If patient < 9 yrs, specify vaccine type: Injected Vaccine 4. Interview: Yes, full date known Patient Proxy 4a. If yes, specify dosage date information: / 4b. If patient < 9 yrs, specify vaccine type: Yes, specific date unknown Injected Vaccine No Date Unknown Combination of both Nasal Spray/FluMist Yes, specific date unknown / No Yes, specific date unknown / No Yes, specific date unknown No 6. If patient < 9 yrs, did patient receive 2 influenza vaccine in current season? 6a. If yes, specify 2 dosage date information: nd / Yes / Unknown Date Unknown Combination of both 5. If patient < 9 yrs, did patient receive any seasonal influenza vaccine in previous seasons? nd Unknown Date Unknown Combination of both Nasal Spray/FluMist / Unknown Date Unknown Combination of both Nasal Spray/FluMist Nasal Spray/FluMist Unknown Yes No No Not Checked Unsuccessful Attempt Unknown type Not Checked Unsuccessful Attempt Unknown type Not Checked Unsuccessful Attempt Unknown type Not Checked Unsuccessful Attempt Unknown type Unknown Unknown Date Unknown N. Miscellaneous 1. Additional Comments: CDC Rev. 07-2017 Page 4 of 4 CS279597
| File Type | application/pdf |
| File Title | Form 0920-0978 2017-18 FluSurv-NET Influenza Hospitalization Surveillan |
| File Modified | 2017-11-17 |
| File Created | 2017-08-04 |