Suspect Respiratory Virus Patient Form

Suspect Respiratory Virus Patient Form

Form Approved
OMB No. 0920-0004
Complete for all patients for whom specimens are submitted to CDC for virus testing. As soon as possible, please 1) notify and send the completed
form to your local/state health department, and 2) include a hard copy of the form along with the 50.34 form for specimen shipment.
Today’s Date:

Name of person filling in form:

Phone:

Hospital / Health Care Facility Name:

STATE:

Email:
COUNTY:

Local Specimen ID (as submitted on 50.34 form for specimen shipment):
If multiple specimens are submitted per patient, please include additional specimen IDs in table below
Patient Sex:

M

F

Age:

Days

Months

Years

Patient’s State of Residence

Race: (More than one box can be checked)
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
White
Ethnicity:
Hispanic
Non-Hispanic
Was patient part of an outbreak?
Y
N If yes, indicate setting:
Hospital
School
Daycare
LTCF
Unknown
Other
Date of symptom onset:
Medical diagnosis (if any, e.g., pneumonia, asthma exacerbation):
Symptoms (mark all that apply):
Fever reported (≥100.4° F / 38° C (If yes, highest recorded temperature
°F / °C))
Chills
Cough
Wheezing
Sore throat
Runny nose
Stuffy nose/congestion
Shortness of breath / difficulty breathing
Tachypnea
Retractions
Cyanosis
Vomiting
Diarrhea
Rash
Lethargy
Seizure
Conjunctivitis
Other (describe):
Does the patient have any comorbid conditions or concurrent risk factors? (mark all that apply):
None
Unknown
Asthma
Reactive airway disease / COPD
Bronchopulmonary dysplasia
Cardiac disease
Immunocompromised
Prematurity, if yes gestational age
Wheezing
Pregnancy
Smoking
Other (describe):
Diagnostic Imaging (Chest radiograph / CT / Other)
If yes, please describe any abnormal findings:

Yes

No

Not Done

Unknown

Yes

No

Unknown

Is/Was the patient: Hypoxic (sat <93%) on room air?
Treated with supplemental oxygen?
Treated with bronchodilators? (if yes, name: ____________________________________)
Treated with steroids? (if yes, name: ___________________________________________)
Treated with antibiotics? (if yes, name: _________________________________________)
Hospitalized? If Yes, admission date:
; discharge date, if applicable:
If Yes, was the patient admitted to the Intensive Care Unit (ICU)?
If Yes was the patient placed on non-invasive ventilation (BiPAP/CPAP)
If Yes, was the patient intubated?
If Yes, was the patient placed on ECMO?
Did the patient die? If Yes, date of death:
General Pathogen Laboratory Testing (mark all that apply)
Pathogen
Pos
Neg Pending Not Done
Influenza A PCR
Influenza B PCR
Influenza Rapid Test
RSV
Human metapneumovirus
Parainfluenzavirus
Adenovirus
Rhinovirus and/or Enterovirus
SARS-CoV-2 (SCV2)
Coronavirus (not MERS/SCV2)
Other:
Submitted Specimen Type(s)
NP
OP
NP/OP (check one)
Nasal wash / aspirate
Sputum

Date Collected

Pathogen
Chlamydophila pneumoniae
Mycoplasma pneumoniae
Legionella pneumophila
Streptococcus pneumoniae
Blood culture
If positive,specify pathogen:
CSF culture
If positive, specify pathogen:
Sputum culture
If positive, specify pathogen:

Specimen ID

Submitted Specimen Type(s)
Bronchoalvelolar lavage (BAL)
Tracheal Aspirate
Stool/Rectal swab

Pos

Neg

Pending

Date Collected

Not Done

Specimen ID

Other:
To be completed by CDC: Patient ID:

Other:
CSID:

CSID:

CSID:

CSID:

CSID:

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 Reports Clearance Officer; 1600 Clifton Road
NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0004).
Version 1.0 (fillable), March 24, 2017