Form No. 57.75GG Form No. 57.75GG Healthcare Worker Influenza Antiviral Medication Adminis

H

OMB No. 0920-0666

Exp. Date 02-29-2008

ealthcare Worker Influenza Antiviral Medication Administration

* Facility ID #: _____________ * Med Admin ID #: __________

Healthcare Worker Demographics:

* HCW ID #: _______________

HCW Name, Last: _________________ First: _____________ Middle: __________

* Gender: ___________ * Date of Birth: _____ / _____ / __________

Information about the Antiviral Medication

Infectious agent: Influenza

* Indication (select one)	* #	* Antiviral medication (enter code from right)	* Start date	* Stop date	* Adverse reactions?
___Prophylaxis ___Treatment			___/___/____ mm dd yyyy	___/___/____ mm dd yyyy	__Y __N __Don’t know
___Prophylaxis ___Treatment			___/___/____ mm dd yyyy	___/___/____ mm dd yyyy	__Y __N __Don’t know
___Prophylaxis ___Treatment			___/___/____ mm dd yyyy	___/___/____ mm dd yyyy	__Y __N __Don’t know
___Prophylaxis ___Treatment			___/___/____ mm dd yyyy	___/___/____ mm dd yyyy	__Y __N __Don’t know

Antiviral medications

AMAN – amantadine

(Symmetrel®)

RIMAN – rimantadine

(Flumadine®)

ZANAM – zanamivir

(Relenza®)

OSELT – oseltamivir

(Tamiflu®)

Adverse reactions to antiviral medication #1: (select all that apply)

____	Acute respiratory failure	____	Facial edema	____	Pulmonary edema
____	Anaphylactic reactions	____	Hallucinations	____	Seizure
____	Arrhythmia	____	Heartblock	____	Serious skin rash
____	Bronchospasm	____	Hypotension, orthostic hypotension	____	Suicide or self-harm attempts
____	Cardiac arrest	____	Leukopenia/neutropenia	____	Swelling of face or tongue
____	Cardiac failure	____	Life threatening overdose	____	Syncope
____	CHF, peripheral edema	____	Malignant arrhythmia	____	Tachycardia
____	Coma	____	Mydriasis (in patients with untreated angle closure glaucoma)	____	Toxic epidermal necrolysis
____	Convulsions	____	Neuroleptic malignant syndrome with abrupt discontinuation or dose reduction	____	Urinary retention
____	Decline in lung function	____	Oropharyngeal edema	____	Other ______________
____	Delirium, delusions, stupor	____	Psychosis		(specify)
____	Dypsnea

Adverse reactions to antiviral medication #2: (select all that apply)

____	Acute respiratory failure	____	Facial edema	____	Pulmonary edema
____	Anaphylactic reactions	____	Hallucinations	____	Seizure
____	Arrhythmia	____	Heartblock	____	Serious skin rash
____	Bronchospasm	____	Hypotension, orthostic hypotension	____	Suicide or self-harm attempts
____	Cardiac arrest	____	Leukopenia/neutropenia	____	Swelling of face or tongue
____	Cardiac failure	____	Life threatening overdose	____	Syncope
____	CHF, peripheral edema	____	Malignant arrhythmia	____	Tachycardia
____	Coma	____	Mydriasis (in patients with untreated angle closure glaucoma)	____	Toxic epidermal necrolysis
____	Convulsions	____	Neuroleptic malignant syndrome with abrupt discontinuation or dose reduction	____	Urinary retention
____	Decline in lung function	____	Oropharyngeal edema	____	Other ______________
____	Delirium, delusions, stupor	____	Psychosis		(specify)
____	Dypsnea

Assurance of Confidentiality: The information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).

Public reporting burden of this collection of information is estimated to average 10 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, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666).

CDC 57.75GG (Front) Ver. 1.1, Effective date XX/XX/200X

Adverse reactions to antiviral medication #3: (select all that apply)

_ Assurance of Confidentiality: The information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 10 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, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.75GG (Front) Ver. 1.1, Rev. 10/01/2005 ___	Acute respiratory failure	____	Facial edema	____	Pulmonary edema
____	Anaphylactic reactions	____	Hallucinations	____	Seizure
____	Arrhythmia	____	Heartblock	____	Serious skin rash
____	Bronchospasm	____	Hypotension, orthostic hypotension	____	Suicide or self-harm attempts
____	Cardiac arrest	____	Leukopenia/neutropenia	____	Swelling of face or tongue
____	Cardiac failure	____	Life threatening overdose	____	Syncope
____	CHF, peripheral edema	____	Malignant arrhythmia	____	Tachycardia
____	Coma	____	Mydriasis (in patients with untreated angle closure glaucoma)	____	Toxic epidermal necrolysis
____	Convulsions	____	Neuroleptic malignant syndrome with abrupt discontinuation or dose reduction	____	Urinary retention
____	Decline in lung function	____	Oropharyngeal edema	____	Other ______________
____	Delirium, delusions, stupor	____	Psychosis		(specify)
____	Dypsnea

Adverse reactions to antiviral medication #4: (select all that apply)

____	Acute respiratory failure	____	Facial edema	____	Pulmonary edema
____	Anaphylactic reactions	____	Hallucinations	____	Seizure
____	Arrhythmia	____	Heartblock	____	Serious skin rash
____	Bronchospasm	____	Hypotension, orthostic hypotension	____	Suicide or self-harm attempts
____	Cardiac arrest	____	Leukopenia/neutropenia	____	Swelling of face or tongue
____	Cardiac failure	____	Life threatening overdose	____	Syncope
____	CHF, peripheral edema	____	Malignant arrhythmia	____	Tachycardia
____	Coma	____	Mydriasis (in patients with untreated angle closure glaucoma)	____	Toxic epidermal necrolysis
____	Convulsions	____	Neuroleptic malignant syndrome with abrupt discontinuation or dose reduction	____	Urinary retention
____	Decline in lung function	____	Oropharyngeal edema	____	Other ______________
____	Delirium, delusions, stupor	____	Psychosis		(specify)
_____	Dypsnea

Custom

Label Label

_______________________ ____/____/____ _______________________ ____/____/____

_______________________ _____________ _______________________ _____________

_______________________ _____________ _______________________ _____________

_______________________ _____________ _______________________ _____________

_______________________ _____________ _______________________ _____________

_______________________ _____________ _______________________ _____________

_______________________ _____________ _______________________ _____________

Comments

CDC 57.75GG (Back) Ver. 1.1, Rev. 12/01/2005