Pediatric Hepatitis of Unknown Etiology Medical Record A

PEDIATRIC HEPATITIS OF UNKNOWN ETIOLOGY MEDICAL RECORD ABSTRACTION FORM
Form Approved: OMB No. 0920-1011
CaseID: _________________________________
Exp. Date 01/31/2023

Version 15 Aug 2022

General Instructions:
Please complete the form for all children who meet the case definition: hepatitis of unknown etiology
(with or without adenovirus testing) among children <10 years with aspartate aminotransferase (AST) or
alanine aminotransferase (ALT) (>500 U/L) since October 1, 2021.
Yellow fields do not need to be submitted to CDC.
CaseID: Please assign using the letter abbreviation for your state/territory followed by a unique ID
(can be either a combination of numeric or alpha characters) assigned by your state
All dates should be in the format MM/DD/YYYY.
Reminder about adenovirus testing:
CDC is recommending adenovirus PCR testing on all specimen types including respiratory, stool,
and blood (including whole blood, plasma or serum) specimens.
CDC requests all residual specimens (adenovirus positive or negative) be submitted to CDC.
Please refer to the specimen protocol for additional instructions on testing/shipping of
specimens. Instructions can be found here: Instructions for Adenovirus Diagnostic Testing,
Typing, and Submission | CDC
Form Submission Instructions:
CDC requests submission of completed forms on a rolling basis. Please upload completed forms to the
ShareFile folder via one of the following:
1. Scanned/electronic copy of the completed form
2. CSV raw data export from REDCap database (if using CDC REDCap data structure in state/local
REDCap instance)
For questions related to form completion or submission instructions, email ncirddvdgast@cdc.gov

1
Public reporting burden of this collection of information is estimated to average 15 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-74 Atlanta, Georgia 30333;
ATTN: PRA (0920-1011)

PEDIATRIC HEPATITIS OF UNKNOWN ETIOLOGY MEDICAL CHART ABSTRACTION FORM
Version: 15 Aug 2022

CASE ID:_________________________________________________

Date form completed: ____/____/_______
DEMOGRAPHICS

Date PUI reported to health department: ____/____/_______

Yellow fields do not need to be submitted to CDC

Patient’s name (Last, First, M.I.) ______________________________

Street Address: ______________________________________

City: __________________________

State:

DOB: ____/____/_______
Ethnicity:

County:

Zip: _________________________

Age: ___________

Sex assigned at birth:
□ Male
□ Refused
□ Days □ Months
□ Female □ Don’t know
□ Years
Race
□ American Indian/Alaska Native □ Native Hawaiian/Pacific Islander
(check all that apply) □ Asian
□ White
□ Black/African American
□ Other (________________)

□ Hispanic or Latino
□ Not Hispanic or Latino
□ Unknown

CLINICAL INFORMATION & LABORATORY MARKERS
Yellow fields do not need to be submitted to CDC. For date of initial evaluation, note date that the child first sought medical care for this illness.
Date of initial evaluation (for this illness): _____/_____/______ □ Unknown
Was the patient hospitalized for this illness?

□ Yes

□ No

□ Unknown

Admission date (initial hospital): ____/____/_______ □ Unknown

If yes…
Date of discharge / death: _____/_____/_______

□ Unknown

Was the patient transferred
from another hospital?
Final patient outcome:

□ Yes □ No
If yes, which hospital?
Date
___/___/________
□ Unknown
____________________________________
Transferred: □ Unknown
□ Survived, discharge home
□ Died
If died, was an
□ Yes □ No
□ Survived, discharged other location □ Unknown
autopsy performed? □ Unknown
Did patient receive a
□ Yes □ No
If yes, which hospital?
Date of
___/___/______
liver transplant (for this illness)? □ Unknown
______________________________________
Transplant: □ Unknown
Is a liver specimen (e.g., biopsy
□ Yes □ No
If yes, which specimen type (check all that apply): □ Biopsy □ Native liver explant
or explant tissue) available?
□ Unknown
Alanine aminotransferase (ALT, U/L) Peak value: ________________
Specimen collection date: ___/___/______ □ Unknown
Aspartate aminotransferase (AST, U/L) Peak value: ______________

Specimen collection date: ___/___/______ □ Unknown

UNDERLYING HEALTH CONDITIONS
Did the patient have any underlying health conditions? □ Yes
□ No
□ Chromosomal/Congenital Disorders, specify ____________________
□ Gastrointestinal/Nutritional Disorders, specify __________________
□ Immunosuppressive Therapy, specify _________________________
□ History of any transplant, specify ____________________________

□ Unknown If yes, check all that apply:
□ Cancer, specify________________________________________
□ Premature Birth (Gestational age at birth: ___________ weeks)
□ Other condition, specify ________________________________

ADENOVIRUS TESTING
CDC recommends adenovirus diagnostic testing on all respiratory, stool, and blood specimens. Any residual specimens should be sent to CDC. Report
any repeat testing in the ‘Other sample, specify’ fields and specify the specimen type.
Specimen Collection
Is specimen available for
Diagnostic Test
Tested/Result
Date (mm/dd/yyyy)
shipping to CDC?
□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unknown
Stool
□ Yes □ No □ Unknown
If tested, specify type: □ Multipanel PCR
□ Other PCR □ Antigen
Respiratory or
□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unknown
□ Yes □ No □ Unknown
throat
If tested, specify type: □ Multipanel PCR
□ Other PCR □ Antigen
Whole blood

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unknown

□ Yes □ No □ Unknown

Plasma

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unknown

□ Yes □ No □ Unknown

Serum

□ Not tested

□ Pos

□ Neg

□ Indeterm

□ Pending

□ Unknown

□ Yes □ No □ Unknown

Other sample,
□ Not tested □ Pos □ Neg □ Indeterm □ Pending □ Unknown
specify: _________
Was typing performed on any
□ Yes □ No
Specimen type: □ Whole blood
□ Plasma
adenovirus positive specimen? □ Unknown
□ Stool
□ Respiratory/throat
Any other clinically relevant information?

□ Yes □ No □ Unknown
□ Serum
□ Unknown

Adenovirus
type: __________