WHO Collaborating Center for Influenza Virus Surveillanc

Form Approved
OMB No. 0920-0004

WHO COLLABORATING CENTER FOR INFLUENZA
INFLUENZA VIRUS SURVEILLANCE
Lab ID Number

Laboratory

/
(City)

Patient's age in years

Report for week ending ____/____/____
Mo. Day Yr.

(State)
<1

1-4

5-24

25-44

45-64

65

Unk

No. of specimens tested for respiratory viruses
No. influenza A(H1N1) (SEASONAL!)
No. influenza A(H3N2)
No. influenza 2009 influenza A (H1N1)
No. influenza A, not subtyped*
No. influenza A, unable to be subtyped**
No. influenza B*
* Subtyping NOT ATTEMPTED
** Subtyping attempted but negative for seasonal H1, seasonal H3, and 2009 influenza A (H1N1).
 If you have no tests or results to report for a week, please fax a form listing the laboratory name and week ending date, but leave the rest of the
form blank.
 If you wish to revise a previous report (e.g., report isolates as “influenza A, subtype unknown” and subsequently subtype the isolates), please
indicate the changes on a copy of the form on which the isolates were initially reported, listing the original week ending date. Clearly mark the copy
as a revised report and fax it to us.

Please call us about unusual isolates: (404-639-3591)
Comments:

A weekly influenza activity report is available on the internet at http://www.cdc.gov/flu/weekly/ .
Public reporting burden of this collection of information is estimated to average 10 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).