Form CDC 52.56 CDC 52.56 Legionellosis Case Report

Patient’s Name:_____________________________________________________ Telephone Number:_________________ Hospital: ____________________

LAST / FIRST / MI

Address:__________________________________________________________________ ____________________Patient Chart No.:___________________

NUMBER / STREET / APT NO / CITY / STATE

ZIP CODE

PATIENT IDENTIFIER INFORMATION IS NOT TRANSMITTED TO CDC

Form Approved OMB No. 0920-0009

CDC • National Center for Immunization and Respiratory Diseases

LEGIONELLOSIS CASE REPORT
(DISEASE CAUSED BY ANY LEGIONELLA SPECIES)
Department of Health & Human Services

Case No.:

Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, 30333
http://www.cdc.gov/legionella/index.htm

hhhhhh

(CDC use only)

PATIENT INFORMATION
1. State Health Dept. Case No.: 2. Reporting State:

3. County of Residence:

4. State of Residence: 5. Occupation:

hh
6a. Date of Birth:

6b. Age:

hh
1 □ Days

hh hh hhhh hhh 2 □ Mos.
Mo.

Day

3 □ Years

Year

7. Sex:

8. Ethnicity:

1
□ Male

1

2
□ Female

9. Race: (check all that apply)

□ Hispanic/Latino 9 □ Unknown
2 □ Not Hispanic/Latino

American Indian/
1
□ Alaska Native
1
□ Asian

1 □ Black or African American
Native Hawaiian or
1
□ Other Pacific Islander
1 □ White

1 □ Unknown

CLINICAL ILLNESS
10. Diagnosis:

11. Date of symptom

(check one)

onset of legionellosis:
h Legionnaires’ Disease (pneumonia, clinical or X-ray diagnosed)
2 h Pontiac Fever (fever and myalgia without pneumonia)
hh hh hhhh
Day
Year
8 h Other (e.g., endocarditis, wound infection): ______________________ Mo.
1

13. Was the patient hospitalized during treatment for legionellosis?

hh hh hhhh

If yes, date of admission:
Mo.

Day

Year

1

□ Yes

2

□ No

9

12. Date of first report to
public health at any level:

hh hh hhhh
Mo.

Day

Year

14. Outcome of illness:

□ Unknown

Hospital name: _____________________________________________

□ Still ill
1
□ Survived 3

City, State:________________________________________________

2
□ Died

9
□ Unknown

EXPOSURE INFORMATION
15. In the 10 days before onset, did the patient spend any nights away from home (excluding healthcare settings)?
(check one)

1 □ Yes* 2 □ No 9 □ Unknown

ACCOMMODATION NAME

If yes, please complete the following table.

ADDRESS

CITY

*If yes, was this case reported to CDC at travellegionella@cdc.gov?

1

□ Yes

2

□ No

STATE

9

ZIP

COUNTRY

ROOM
NUMBER

DATES OF STAY
ARRIVAL

DEPARTURE

□ Unknown

16. In the 10 days before onset, did the patient get in or spend time near a whirlpool spa (i.e., hot tub)?
(check one) 1 □ Yes 2 □ No 9 □ Unknown If yes, describe where:__________________________ If yes, list dates: _________________________
17. In the 10 days before onset, did the patient use a nebulizer, CPAP, BiPAP or any other respiratory therapy equipment for the treatment of sleep
apnea, COPD, asthma or for any other reason?
(check one) 1 □ Yes 2 □ No 9 □ Unknown If yes, does this device use a humidifier? 1 □ Yes 2 □ No 9 □ Unknown
If yes, what type of water is used in the device? (check all that apply) 1 □ Sterile 1 □ Distilled 1 □ Bottled 1 □ Tap 1 □ Other 1 □ Unknown
18. In the 10 days before onset, did the patient visit or stay in a healthcare setting (e.g., hospital, long term care/rehab/skilled nursing facility, clinic)?
(check one) 1 □ Yes 2 □ No 9 □ Unknown If yes, please complete the following table.
TYPE OF HEALTHCARE
SETTING / FACILITY
(CHECK ONE)

TYPE OF EXPOSURE
(CHECK ONE)

NAME OF
FACILITY

IS THIS
FACILITY ALSO
A TRANSPLANT
CENTER?

1 □ Hospital

1 □ Inpatient

1 □ Yes

2 □ Long term care

2 □ Outpatient

2 □ No

3 □ Clinic

3 □ Visitor or volunteer

9 □ Unknown

8 □ Other:_______________

4 □ Employee

1 □ Hospital

1 □ Inpatient

1 □ Yes

2 □ Long term care

2 □ Outpatient

2 □ No

3 □ Clinic

3 □ Visitor or volunteer

9 □ Unknown

8 □ Other:_______________

4 □ Employee

REASON FOR VISIT

CITY

STATE

DATE OF VISIT /
ADMISSION
START DATE

END DATE

Public reporting burden of this collection of information is estimated to average 20 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, Project Clearance Officer, 1600 Clifton Road,
MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0009). Do not send the completed form to this address. While your response is voluntary your cooperation is necessary for the understanding and control of this disease.
CDC 52.56 Rev. 06/2011
CS218324

Legionellosis Case Report
– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –

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State Health Dept. Case No.: ___________________________________

19. Was this case associated with a healthcare exposure: (check one)
1 □ Definitely: Patient was hospitalized or a resident of a long term care facility

3 □ Possibly: Patient had exposure to a healthcare facility for a portion

2 □ No: No exposure to a healthcare facility in the 10 days prior to onset

8 □ Other (specify) _______________________________________

for the entire 10 days prior to onset

of the 10 days prior to onset

9 □ Unknown

20. In the 10 days before onset, did the patient visit or stay in an assisted living facility or senior living facility? (check one) 1 □ Yes 2 □ No 9 □ Unknown
TYPE OF FACILITY
1 □ Assisted Living

TYPE OF EXPOSURE

NAME OF FACILITY

CITY

STATE

DATE OF VISIT
START DATE

END DATE

1 □ Resident
2 □ Visitor or Volunteer
3 □ Employee

2

□ Senior Living

(Includes retirement
homes without skilled
nursing or personal care)

1 □ Resident
2 □ Visitor or Volunteer
3 □ Employee

21. Was this case associated with a known outbreak or possible cluster?

(check one)

1 □ Yes 2 □ No 9 □ Unknown

If yes, specify name of facility, city, and state of outbreak: ___________________________________________________________________________
LABORATORY DATA
PLEASE CHECK ALL METHODS OF DIAGNOSIS WHICH APPLY:

h CONFIRMED CASE
1 h Urine Antigen Positive: If yes,

Date Collected: hh hh hhhh

h SUSPECT CASE
4 h Fourfold rise in antibody titer OTHER THAN Legionella

1

Mo.

Day

2

pneumophila serogroup 1 or to multiple species or
serogroups of Legionella using pooled antigen: If yes,

Year

hh hh hhhh

Initial (acute) titer:_____________ Date Collected:
Mo.

2

□
4 □
Site: 1

□
blood 8 □

lung biopsy 2

Day

Convalescent titer:____________ Date Collected:
Mo.

3

□

pleural fluid

5

Immunohistochemistry (IHC) Positive: If yes,

Date Collected:

□
4 □
Site: 1

h Fourfold rise in antibody titer to

hh hh hhhh
Day

Year

hh hh hhhh

Convalescent titer:____________ Date Collected:
Mo.

Day

hh hh hhhh
Mo. Day

□
blood 8 □
lung biopsy 2

Year

respiratory secretions (e.g., sputum, BAL)

3

□

pleural fluid

other (specify)________________________________________

Species:_______________________________________ Serogroup:______________________

Legionella pneumophila serogroup 1: If yes,

Initial (acute) titer:_____________ Date Collected:
Mo.

Year

h Direct Fluorescent Antibody (DFA) or

other (specify)________________________________________

Species: _______________________________________ Serogroup: _____________________

3

Day

Species:_______________________________________ Serogroup:______________________

Year

respiratory secretions (e.g., sputum, BAL)

Year

hh hh hhhh

h Culture Positive: If yes,
Date Collected: hh hh hhhh

Mo.

Day

Year

h Nucleic Acid Assay (e.g., PCR): If yes,
Date Collected: hh hh hhhh
6

Mo.

□
4 □
Site: 1

Day

□
blood 8 □
lung biopsy 2

Year

respiratory secretions (e.g., sputum, BAL)

3

□

pleural fluid

other (specify)________________________________________

Species:_______________________________________ Serogroup:______________________

INTERVIEWER IDENTIFICATION

REPORTING INSTRUCTIONS

Interviewer’s Name:

State Health Dept. Official who reviewed this report:

Affiliation:

Title:

Telephone No.:

Telephone No.:

Local Health Dept. Please submit this document to:

State/DHD/SSS via your CD clerk
State Health Dept. Return completed form to:

Respiratory Diseases Branch, Mailstop C25
Office of Infectious Diseases
Centers for Disease Control and Prevention
1600 Clifton Rd. NE, Atlanta, GA 30333
COMMENTS

____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
CDC 52.56 Rev. 06/2011

Legionellosis Case Report

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