Antiviral-Resistant Influenza Infection Case Report Form

Antiviral-Resistant Influenza Infection Case Report Form
Form Approved
OMB No. 0920-0004
Exp. Date 8/31/2014
I. Specimen Information
State Lab Specimen ID
Specimen Collection State
Patient County of residence
Patient State of residence

_______________
_______________
_______________
_______________

Reason for Antiviral Resistance Test:
 Requested for Clinical Indication
 Surveillance
 Other _________________
Date of Specimen Collection:
__ __/ __ __/ __ __ __ __

Specimen Type:
 Nasopharyngeal (NP) Swab
 Nasal swab
 Oropharyngeal Swab
 Bronchoalveolar Lavage
 Other ___________________

II. Basic Information If information is from patient interview please READ: I’m going to ask you for some information about yourself
(your child) and your (the child’s) illness. To help you remember, I am going to tell you the date that your nose/ throat swab was taken
to test for flu (use specimen collection date in section I). Please feel free to look at a calendar to help you remember dates. I can wait
until you find one.
Age: __ __  yrs  months
Sex:  Male  Female
Ethnicity:
 Hispanic or Latino
 Not Hispanic or Latino

Race:
 American Indian/ Alaska
Native
 Asian or Pacific Islander
 Black or African American
 White

Illness History:
Date of illness onset:
__ __/ __ __/ __ __ __ __
Hospitalized for illness?
Yes
No
Unknown

Patient Outcome:
 At Home
 At Extended Care Facility
 Currently Hospitalized
 Dead (Was it influenza-related?
Yes  No  Unknown)
 Unknown

III. Pre-existing Medical Conditions
Did a doctor ever tell you that you (your child) had any of
the following conditions? (Please check all that apply)
 Diabetes Mellitus
 Chronic kidney disease
 Asthma
 Chronic lung disease (non-asthma), specify_______

 Immunosuppressive condition (complete section IX),
 Chronic Heart Disease, specify: ___________________
 Chronic Liver Disease, specify: ___________________
 Morbid obesity: Height _______ Weight _______
 Other Condition, specify: ___________________
If female aged >16 years, were you pregnant at time of specimen
collection:  Yes  No  Unknown Trimester ______

IV. Hospitalized Patient Information (skip to section V if patients is not hospitalized)
Date of hospital admission: __ __/ __ __/ __ __ __ __
Reason for Hospital Admission:  Respiratory Illness

Date of hospital discharge: __ __/ __ __/ __ __ __ __
 Other, specify:

During hospitalization, was patient:
In Intensive Care Unit?
 Yes  No  Unknown

Mechanically Ventilated?
 Yes  No  Unknown

On Vasopressors?
 Yes  No  Unknown

Renal Failure requiring Dialysis?
 Yes  No  Unknown

V. Influenza Antiviral Medication History
Received influenza antiviral medications including oseltamivir (Tamiflu®) or zanamivir (Relenza®)?
 Yes  No (skip to section VI)  Unknown (skip to section VI)
If yes, Please check all below that apply:

Public reporting burden of this collection of information is estimated to average 30 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 (0920‐0004).

FAX COMPLETED FORM TO: 404-639-3866
 Oseltamivir (Tamiflu)
Dose:
 75mg  Other _______
Frequency:  QD  BID  Other _____
Indication:  Treatment  Prevention
Location:
 Outpatient  Inpatient
Start Date: __ __/ __ __/ __ __ __ __
End Date: __ __/ __ __/ __ __ __ __

CDC ID (CDC use only): _______________

 Zanamivir (Relenza)
Dose:
 10mg
 Other _______
Route:
 Inhaled  IV (experimental)
Frequency:  QD  BID  Other _____
Indication:  Treatment  Prevention
Location:
 Outpatient  Inpatient
Start Date: __ __/ __ __/ __ __ __ __
End Date: __ __/ __ __/ __ __ __ __

Patient finished all of the pills (or suspension)?
Information on antiviral treatment is from

 Additional/other Agent
Name:
_______________________
Dose:
_______________________
Route:
 Oral  IV  Inhaled
Frequency:  BID
 Other _______
Indication:  Treatment  Prevention
Location:
 Outpatient  Inpatient
Start Date: __ __/ __ __/ __ __ __ __
End Date: __ __/ __ __/ __ __ __ __
 Yes  No  Unknown

 medical record  self report

Comments about antiviral therapy: (e.g. other courses of antiviral treatment, reasons for poor compliance, etc.)

VI. Influenza Vaccine History
Did you (your child) receive the influenza vaccine this year?

 Yes  No  Unknown

VII. Transmission History
1.

At the time you (your child) became ill, where did you
reside?

 Single Family House (1 housing unit in building)
 Multi-Family Housing ( > 1 unit in building)
 Facility (hospital, long term care, nursing home, jail, etc)
 University Dorm or boarding school
 Other, specify: _____________________________

2.

How many people live in your household? [a household is defined as the place where you regularly sleep and eat]

3.

During the week before illness, did anyone else in the household have flu or a respiratory illness?
If Yes, Did anyone else other than you in the household get a diagnosis of flu?

4.

During the week before illness, did anyone else in the household
receive any antiviral medications?
If yes, What was the name of the antiviral agent?

5.

_____

 Yes  No  Unknown
If yes, how many? ________
 Yes  No  Unknown
If yes, how many? ________

 Yes (  for treatment  for prevention)
 No
 Unknown
 Tamiflu Relenza Unknown Other specify______

Did you travel outside of your typical residence area during the 7 days prior to illness?

 Yes

 No

 Unknown

If yes, Where did you travel to? Country__________ state______ city/town_____________
Dates of travel? __ __/ __ __/ __ __ __ __ to __ __/ __ __/__ __ __ __
If the patient is a child, university student or living in a facility (e.g. LTCF), ask the following questions, if not, skip to the next
section.
6. Were others at your (your child’s) school/residency also sick at the same time as your (the child’s) flu illness?

 Yes

 No

 DK

If yes, where do you (your child) go to school/ reside?

________________________________

VIII. Immunosuppression Details (skip to section IX if not immunosuppressed) (check all that apply)

FAX COMPLETED FORM TO: 404-639-3866
 HIV/AIDS: CD4 count ≤ 200:
On antiretroviral therapy:
Unknown

 Yes
 Yes

 No
 No

CDC ID (CDC use only): _______________
 Unknown


 Solid Tumor Malignancy: Specify Type (s):
Diagnosis Date: ____________
Date most recent chemotherapy: ____________
 Hematologic Malignancy: Specify Type (s):
Diagnosis Date:____________
Date most recent chemotherapy: ____________
 Receipt of Stem Cell Transplant
Specify Type (s):

Date: ____________

 Receipt of Solid Organ Transplant
Specify Type (s):

Date:____________

 Autoimmune Disorder
Describe:

Diagnosis Date: ____________

 Other condition (Lupus, Rheumatoid Arthritis, Crohns, etc)
Describe:
Diagnosis Date: ____________

Any immunosuppressive therapy during the year prior to influenza
specimen collection:  Yes  No  Unknown
Steroids (Systemic)
Dose ______________
Route ______________
Start Date ___________
Duration ____________
Antibody Based Agents
 Alemtuzumab
 Basiliximab
 Daclizumab
 Trastuzumab
 Rituximab
 Infliximab
 OKT-3
Immunosuppressants
 Cyclosporine
 Azathioprine
 Leflunomide

Anti-rejection Agents
 Tacrolimus
 Sirolimus
 Mycophenolate Mofetil
 Anti-thymocyte Globulin
Chemotherapeutic Agents
 Cyclophosphamide
 Methotrexate
 Fludarabine
 Imatinib
Chemotherapy Regimens (e.g.
CHOP)
_________________________
_________________________
Agents not mentioned above
___________________________
_______________________

Dates of most recent immunosuppressive therapy:
Results of CBC closest to time of influenza testing (preferably within 24 hours):
Total White Blood Cell Count: ______
Absolute Neutrophil Count: ______

Date of CBC: __ __/ __ __/ __ __ __ __
Absolute Lymphocyte Count: ______

IX. Additional Comments

X. Sender Information
First Name:
Institution Name:

Last Name:
Email Address:

Date of Survey Completion: __ __/ __ __/ __ __ __ __
Telephone Number: