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DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Disease Control
and Prevention (CDC)
Atlanta, Georgia 30333
Q Fever Case Report
Retrieve Data
Form Approved
OMB 0920-0009
Centers for Disease Control and Prevention Fax: (404) 639-2778
CDC#
(1-4)
– PATIENT/PHYSICIAN INFORMATION –
Patient's
name:
Date submitted: __ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(5-6)
(7-8)
(9-12)
Physician’s
Phone
name:
no.:
Address:
(number, street)
NETSS ID No.: (if reported)
City:
Case ID
Site (19-21)
(13-18)
State (22-23)
– DEMOGRAPHICS –
1. State of
2. County of
residence:
residence:
4. Date of birth:
3. Zip code:
5. Sex:
■ White
4 ■ Asian
2 ■ Black
5 ■ Pacific Islander
American Indian 9 ■ Not specified
3■
Alaskan Native
1
1
2
__ __ / __ __ /__ __ __ __
__ __ __ __ __ __ __ __ __
(26-50)
(24-25)
(60-61) (62-63)
(51-59)
(64-67)
8. Occupation at date of onset of illness (Check all that apply)
■ wool or felt plant (71)
■ tannery or rendering plant
3 ■ dairy (73)
4 ■ veterinarian (74)
5 ■ medical research (75)
2
6
■ Cattle (82) 3 ■ Goats (84) 5 ■ Cats (86)
■ Sheep (83) 4 ■ Pigeons (85) 6 ■ Rabbits (87)
8 ■ Other (please specify) (88)
1
7
(72)
2
________________________________
10. Any exposure to birthing animals?
11. Exposure to unpasteurized milk?
(89)
12. Any travel in last year?
_______________________________________
13. Other family member with
similar illness in last year?
(91-92)
(90)
■ Yes 2 ■ No 9 ■ Unk
If yes, which
animal _____________________
■ Yes 2 ■ No 9 ■ Unk
If yes, which
animal _____________________
1
1
If yes, State
■ Yes (70)
2 ■ No
9 ■ Unk
1
9. Any contact with animals within
2 months prior to onset? (check all that apply)
■ animal research (76)
1 0 ■ live in household with person
occupationally related to above? (80)
■ slaughterhouse worker (77)
8 ■ laboratory worker (78)
8 8 ■ other (please specify) (81)
9 ■ rancher (79)
1
7. Hispanic
ethnicity:
6. Race: (69)
(68)
■ Male
■ Female
9 ■ Not
specified
(mm/dd/yyyy)
(93)
County __________________
1
Foreign Country _____________________________
■ Yes
2
■ No
9
■ Unk
– CLINICAL FINDINGS –
14. Date of Onset of Symptoms:
15. Clinical Signs and syndromes (check all that apply)
■ fever (>100.5) (102) 4 ■ malaise (105) 7 ■ headache (108)
■ myalgia (103)
5 ■ rash (106)
8 ■ splenomegaly (109)
3 ■ retrobulbar pain (104) 6 ■ cough (107) 9 ■ hepatomegaly (110)
__ __ /__ __ /__ __ __ __
(94-95)
(96-97)
(98-101)
(mm/dd/yyyy)
■ pneumonia (111) 8 8 ■ Other (please specify) (114)
■ hepatitis (112)
__________________________________
1 2 ■ endocarditis (113)
1
10
2
11
16. Any pre-existing medical conditions? (check all that apply)
■ immunocompromised (115) 3 ■ valvular heart disease or vascular graft (117)
2 ■ pregnancy (116) 8 ■ Other __________________________________ (118)
1
17. Was patient hospitalized
18. Did patient die from complications
because of this illness? (119)
of this illness? (120) (If yes, date)
(mm/dd/yyyy)
1
■ Yes
2
■ No
9
■ Unk
1
■ Yes
2
■ No
9
■ Unk
__ __/__ __/__ __ __ __
(121-22) (123-24)
(125-28)
– LABORATORY DATA –
19. Name of
laboratory:________________________________________________
20.
City:________________________________ State: __ __ Zip: __ __ __ __ __ - __ __ __ __
Phase I Antigen
Serology
(Check only if specific
assay was performed)
Serology 1 (mm/dd/yyyy)
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
(141-42) (143-44)
(153-54) (155-56)
(165-66) (167-68)
(133-36)
■ Yes
1
■ Yes
1
_ _ _ _ _ 2■ No (149)
■ Yes
_ _ _ _ _ 2■ No (138) _ _ _ _ _
1■ Yes
_ _ _ _ _ 2■ No (139) _ _ _ _ _
1■ Yes
_ _ _ _ _ 2■ No (140) _ _ _ _ _
(157-60)
Titer or OD* Positive?
■ Yes
1
_ _ _ _ _ 2■ No (161)
■ Yes
2■ No (150)
_____
1■ Yes
2■ No (151)
_____
1■ Yes
2■ No (152)
_____
1
(169-72)
Titer or OD* Positive?
■ Yes
1
_ _ _ _ _ 2■ No (173)
■ Yes
2■ No (162)
_____
1■ Yes
2■ No (163)
_____
1■ Yes
2■ No (164)
_____
1
■ Yes
2■ No (174)
1■ Yes
2■ No (175)
1■ Yes
2■ No (176)
1
* Check only if specific assay was performed.
22. Other
Positive?
Diagnostic Tests ?*
PCR
Immunostain
Culture
➮
Other
test: ______________
(145-48)
Titer or OD* Positive?
1
Complement
Fixation
Serology 2 (mm/dd/yyyy)
__ __/__ __/__ __ __ __
_ _ _ _ _ 2■ No (137)
IFA - IgM
Serology 1 (mm/dd/yyyy)
(129-30) (131-32)
Titer or OD* Positive?
IFA - IgG
Phase II Antigen
Serology 2 (mm/dd/yyyy)
■ Yes
1 ■ Yes
1 ■ Yes
1
■ No (178)
2 ■ No (179)
2 ■ No (180)
2
Sample(s) tested:
*IFA or CF “Titer” or Other test: ELISA (EIA) Optical Density “OD” value.
21. Was there a fourfold change in antibody titer between the two serum specimens?
■ Yes 2■ No (177)
1
– FINAL DIAGNOSIS –
23. Classify case based on the CDC case definition (see criteria below):
1
■
CONFIRMED
2
■
PROBABLE
State Health Department Official who reviewed this report:
(181)
Confirmed Q fever: A clinically compatible case that is laboratory confirmed with 1) a fourfold change in
antibody titer to Coxiella burnetii antigen by IFA or CF antibody test, or 2) a positive PCR assay, or
3) culture of C. burnetii from a clinical specimen, or 4) positive immunostaining of C. burnetii in tissue.
Name: ___________________________________________________________
Title: ___________________________________ Date: __ __ /__ __/__ __ __ __
(mm/dd/yyyy)
Probable Q Fever: A clinically compatible case with single supportive IgG or IgM titer as defined by testing lab.
Public reporting burden of this collection of information is estimated to average 10 minutes per response. 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. Please send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Rd., NE (MS D-74); Atlanta, GA 30333; ATTN: PRA (0920-0009).
CDC 55.1 03/2002
1st COPY STATE HEALTH DEPARTMENT
Save Data
Print
Q FEVER CASE REPORT
Email Form
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Disease Control
and Prevention (CDC)
Atlanta, Georgia 30333
Q Fever Case Report
Form Approved
OMB 0920-0009
Centers for Disease Control and Prevention Fax: (404) 639-2778
(1-4)
CDC#
PATIENT/PHYSICIAN
INFORMATION –
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jDEMOGRAPHICS
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–DvR
–
1. State of
2. County of
residence:
residence:
4. Date of birth:
3. Zip code:
5. Sex:
■ White
4 ■ Asian
2 ■ Black
5 ■ Pacific Islander
American Indian 9 ■ Not specified
3■
Alaskan Native
1
1
2
__ __ __ __ __ - __ __ __ __
(26-50)
(24-25)
(51-59)
__ __ / __ __ / __ __ __
(60-61) (62-63)
(64-67)
__
8. Occupation at date of onset of illness (Check all that apply)
■ wool or felt plant (71)
■ tannery or rendering plant
3 ■ dairy (73)
4 ■ veterinarian (74)
5 ■ medical research (75)
2
6
■ Cattle (82) 3 ■ Goats (84) 5 ■ Cats (86)
■ Sheep (83) 4 ■ Pigeons (85) 6 ■ Rabbits (87)
8 ■ Other (please specify) (88)
1
7
(72)
2
________________________________
10. Any exposure to birthing animals?
11. Exposure to unpasteurized milk?
(89)
12. Any travel in last year?
_______________________________________
13. Other family member with
similar illness in last year?
(91-92)
(90)
■ Yes 2 ■ No 9 ■ Unk
If yes, which
animal _____________________
■ Yes 2 ■ No 9 ■ Unk
If yes, which
animal _____________________
1
1
If yes, State
■ Yes (70)
2 ■ No
9 ■ Unk
1
9. Any contact with animals within
2 months prior to onset? (check all that apply)
■ animal research (76)
1 0 ■ live in household with person
occupationally related to above? (80)
■ slaughterhouse worker (77)
8 ■ laboratory worker (78)
8 8 ■ other (please specify) (81)
9 ■ rancher (79)
1
7. Hispanic
ethnicity:
6. Race: (69)
(68)
■ Male
■ Female
9 ■ Not
specified
(mm/dd/yyyy)
State (22-23)
(93)
County __________________
1
Foreign Country _____________________________
■ Yes
2
■ No
9
■ Unk
– CLINICAL FINDINGS –
14. Date of Onset of Symptoms:
15. Clinical Signs and syndromes (check all that apply)
■ fever (>100.5) (102) 4 ■ malaise (105) 7 ■ headache (108)
■ myalgia (103)
5 ■ rash (106)
8 ■ splenomegaly (109)
3 ■ retrobulbar pain (104) 6 ■ cough (107) 9 ■ hepatomegaly (110)
__ __ /__ __ /__ __ __ __
(94-95)
(96-97)
(98-101)
(mm/dd/yyyy)
■ pneumonia (111) 8 8 ■ Other (please specify) (114)
■ hepatitis (112)
__________________________________
1 2 ■ endocarditis (113)
1
10
2
11
16. Any pre-existing medical conditions? (check all that apply)
■ immunocompromised (115) 3 ■ valvular heart disease or vascular graft (117)
2 ■ pregnancy (116) 8 ■ Other __________________________________ (118)
1
17. Was patient hospitalized
18. Did patient die from complications
because of this illness? (119)
of this illness? (120) (If yes, date)
(mm/dd/yyyy)
1
■ Yes
2
■ No
9
■ Unk
1
■ Yes
2
■ No
9
■ Unk
__ __/__ __/__ __ __ __
(121-22) (123-24)
(125-28)
– LABORATORY DATA –
19. Name of
laboratory:________________________________________________
20.
City:________________________________ State: __ __ Zip: __ __ __ __ __ - __ __ __ __
Phase I Antigen
Serology
(Check only if specific
assay was performed)
Serology 1 (mm/dd/yyyy)
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
(141-42) (143-44)
(153-54) (155-56)
(165-66) (167-68)
(133-36)
■ Yes
1
■ Yes
1
_ _ _ _ _ 2■ No (149)
■ Yes
_ _ _ _ _ 2■ No (138) _ _ _ _ _
1■ Yes
_ _ _ _ _ 2■ No (139) _ _ _ _ _
1■ Yes
_ _ _ _ _ 2■ No (140) _ _ _ _ _
(157-60)
Titer or OD* Positive?
■ Yes
1
_ _ _ _ _ 2■ No (161)
■ Yes
2■ No (150)
_____
1■ Yes
2■ No (151)
_____
1■ Yes
2■ No (152)
_____
1
(169-72)
Titer or OD* Positive?
■ Yes
1
_ _ _ _ _ 2■ No (173)
■ Yes
2■ No (162)
_____
1■ Yes
2■ No (163)
_____
1■ Yes
2■ No (164)
_____
1
■ Yes
2■ No (174)
1■ Yes
2■ No (175)
1■ Yes
2■ No (176)
1
* Check only if specific assay was performed.
22. Other
Positive?
Diagnostic Tests ?*
PCR
Immunostain
Culture
➮
Other
test: ______________
(145-48)
Titer or OD* Positive?
1
Complement
Fixation
Serology 2 (mm/dd/yyyy)
__ __/__ __/__ __ __ __
_ _ _ _ _ 2■ No (137)
IFA - IgM
Serology 1 (mm/dd/yyyy)
(129-30) (131-32)
Titer or OD* Positive?
IFA - IgG
Phase II Antigen
Serology 2 (mm/dd/yyyy)
■ Yes
1 ■ Yes
1 ■ Yes
1
■ No (178)
2 ■ No (179)
2 ■ No (180)
2
Sample(s) tested:
*IFA or CF “Titer” or Other test: ELISA (EIA) Optical Density “OD” value.
21. Was there a fourfold change in antibody titer between the two serum specimens?
■ Yes 2■ No (177)
1
– FINAL DIAGNOSIS –
23. Classify case based on the CDC case definition (see criteria below):
1
■
CONFIRMED
2
■
PROBABLE
State Health Department Official who reviewed this report:
(181)
Confirmed Q fever: A clinically compatible case that is laboratory confirmed with 1) a fourfold change in
antibody titer to Coxiella burnetii antigen by IFA or CF antibody test, or 2) a positive PCR assay, or
3) culture of C. burnetii from a clinical specimen, or 4) positive immunostaining of C. burnetii in tissue.
Name: ___________________________________________________________
Title: ___________________________________ Date: __ __ /__ __/__ __ __ __
Probable Q Fever: A clinically compatible case with single supportive IgG or IgM titer as defined by testing lab.
(mm/dd/yyyy)
Public reporting burden of this collection of information is estimated to average 10 minutes per response. 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. Please send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Rd., NE (MS D-74); Atlanta, GA 30333; ATTN: PRA (0920-0009).
CDC 55.1 03/2002
2nd COPY – CDC
Q FEVER CASE REPORT
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Disease Control
and Prevention (CDC)
Atlanta, Georgia 30333
Q Fever Case Report
Form Approved
OMB 0920-0009
Centers for Disease Control and Prevention Fax: (404) 639-2778
CDC#
(1-4)
– PATIENT/PHYSICIAN INFORMATION –
Patient's
name:
Date submitted: __ __ /__ __/__ __ __ __ (mm/dd/yyyy)
(5-6)
(7-8)
(9-12)
Physician’s
Phone
name:
no.:
Address:
(number, street)
NETSS ID No.: (if reported)
City:
Case ID
Site (19-21)
(13-18)
State (22-23)
– DEMOGRAPHICS –
1. State of
2. County of
residence:
residence:
4. Date of birth:
3. Zip code:
5. Sex:
■ White
4 ■ Asian
2 ■ Black
5 ■ Pacific Islander
American Indian 9 ■ Not specified
3■
Alaskan Native
1
1
2
__ __ __ __ __ - __ __ __ __
(26-50)
(24-25)
(51-59)
__ __ / __ __ / __ __ __
(60-61) (62-63)
(64-67)
__
8. Occupation at date of onset of illness (Check all that apply)
■ wool or felt plant (71)
■ tannery or rendering plant
3 ■ dairy (73)
4 ■ veterinarian (74)
5 ■ medical research (75)
2
6
■ Cattle (82) 3 ■ Goats (84) 5 ■ Cats (86)
■ Sheep (83) 4 ■ Pigeons (85) 6 ■ Rabbits (87)
8 ■ Other (please specify) (88)
1
7
(72)
2
________________________________
10. Any exposure to birthing animals?
11. Exposure to unpasteurized milk?
(89)
12. Any travel in last year?
_______________________________________
13. Other family member with
similar illness in last year?
(91-92)
(90)
■ Yes 2 ■ No 9 ■ Unk
If yes, which
animal _____________________
■ Yes 2 ■ No 9 ■ Unk
If yes, which
animal _____________________
1
1
If yes, State
■ Yes (70)
2 ■ No
9 ■ Unk
1
9. Any contact with animals within
2 months prior to onset? (check all that apply)
■ animal research (76)
1 0 ■ live in household with person
occupationally related to above? (80)
■ slaughterhouse worker (77)
8 ■ laboratory worker (78)
8 8 ■ other (please specify) (81)
9 ■ rancher (79)
1
7. Hispanic
ethnicity:
6. Race: (69)
(68)
■ Male
■ Female
9 ■ Not
specified
(mm/dd/yyyy)
(93)
County __________________
1
Foreign Country _____________________________
■ Yes
2
■ No
9
■ Unk
– CLINICAL FINDINGS –
14. Date of Onset of Symptoms:
15. Clinical Signs and syndromes (check all that apply)
■ fever (>100.5) (102) 4 ■ malaise (105) 7 ■ headache (108)
■ myalgia (103)
5 ■ rash (106)
8 ■ splenomegaly (109)
3 ■ retrobulbar pain (104) 6 ■ cough (107) 9 ■ hepatomegaly (110)
__ __ /__ __ /__ __ __ __
(94-95)
(96-97)
(98-101)
(mm/dd/yyyy)
■ pneumonia (111) 8 8 ■ Other (please specify) (114)
■ hepatitis (112)
__________________________________
1 2 ■ endocarditis (113)
1
10
2
11
16. Any pre-existing medical conditions? (check all that apply)
■ immunocompromised (115) 3 ■ valvular heart disease or vascular graft (117)
2 ■ pregnancy (116) 8 ■ Other __________________________________ (118)
1
17. Was patient hospitalized
18. Did patient die from complications
because of this illness? (119)
of this illness? (120) (If yes, date)
(mm/dd/yyyy)
1
■ Yes
2
■ No
9
■ Unk
1
■ Yes
2
■ No
9
■ Unk
__ __/__ __/__ __ __ __
(121-22) (123-24)
(125-28)
– LABORATORY DATA –
19. Name of
laboratory:________________________________________________
20.
City:________________________________ State: __ __ Zip: __ __ __ __ __ - __ __ __ __
Phase I Antigen
Serology
(Check only if specific
assay was performed)
Serology 1 (mm/dd/yyyy)
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
(141-42) (143-44)
(153-54) (155-56)
(165-66) (167-68)
(133-36)
■ Yes
1
■ Yes
1
_ _ _ _ _ 2■ No (149)
■ Yes
_ _ _ _ _ 2■ No (138) _ _ _ _ _
1■ Yes
_ _ _ _ _ 2■ No (139) _ _ _ _ _
1■ Yes
_ _ _ _ _ 2■ No (140) _ _ _ _ _
(157-60)
Titer or OD* Positive?
■ Yes
1
_ _ _ _ _ 2■ No (161)
■ Yes
2■ No (150)
_____
1■ Yes
2■ No (151)
_____
1■ Yes
2■ No (152)
_____
1
(169-72)
Titer or OD* Positive?
■ Yes
1
_ _ _ _ _ 2■ No (173)
■ Yes
2■ No (162)
_____
1■ Yes
2■ No (163)
_____
1■ Yes
2■ No (164)
_____
1
■ Yes
2■ No (174)
1■ Yes
2■ No (175)
1■ Yes
2■ No (176)
1
* Check only if specific assay was performed.
22. Other
Positive?
Diagnostic Tests ?*
PCR
Immunostain
Culture
➮
Other
test: ______________
(145-48)
Titer or OD* Positive?
1
Complement
Fixation
Serology 2 (mm/dd/yyyy)
__ __/__ __/__ __ __ __
_ _ _ _ _ 2■ No (137)
IFA - IgM
Serology 1 (mm/dd/yyyy)
(129-30) (131-32)
Titer or OD* Positive?
IFA - IgG
Phase II Antigen
Serology 2 (mm/dd/yyyy)
■ Yes
1 ■ Yes
1 ■ Yes
1
■ No (178)
2 ■ No (179)
2 ■ No (180)
2
Sample(s) tested:
*IFA or CF “Titer” or Other test: ELISA (EIA) Optical Density “OD” value.
21. Was there a fourfold change in antibody titer between the two serum specimens?
■ Yes 2■ No (177)
1
– FINAL DIAGNOSIS –
23. Classify case based on the CDC case definition (see criteria below):
1
■
CONFIRMED
2
■
PROBABLE
State Health Department Official who reviewed this report:
(181)
Confirmed Q fever: A clinically compatible case that is laboratory confirmed with 1) a fourfold change in
antibody titer to Coxiella burnetii antigen by IFA or CF antibody test, or 2) a positive PCR assay, or
3) culture of C. burnetii from a clinical specimen, or 4) positive immunostaining of C. burnetii in tissue.
Name: ___________________________________________________________
Title: ___________________________________ Date: __ __ /__ __/__ __ __ __
Probable Q Fever: A clinically compatible case with single supportive IgG or IgM titer as defined by testing lab.
(mm/dd/yyyy)
Public reporting burden of this collection of information is estimated to average 10 minutes per response. 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. Please send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Rd., NE (MS D-74); Atlanta, GA 30333; ATTN: PRA (0920-0009).
CDC 55.1 03/2002
3rd COPY LOCAL HEALTH DEPARTMENT
Q FEVER CASE REPORT
| File Type | application/pdf |
| File Title | Q-Fever Case Report |
| Subject | Q-Fever Case Report |
| Author | maw2/tgd2/dgg2 |
| File Modified | 2006-06-08 |
| File Created | 2002-03-18 |