Form Approved
Human
Infection with Novel Influenza A Virus
Case Report Form
OMB No. 0920-0004
State: Date reported to health department: / / (MM/DD/YYYY) Date interview completed: / / (MM/DD/YYYY) State Epi ID: State Lab ID:
_________
:_____________________
____________________
At the time of this report, is the case
What is the subtype? (If a variant subtype is selected, please complete the Human Infection with Novel Influenza A Variant Module. If an avian subtype is selected, please complete the Human Infection with Novel Influenza A Virus Avian Module).
Influenza
A(H1N1)
variant Influenza
A(H1N2)
variant Influenza
A(H3N2)
variant Influenza
A(H5N1)
avian
Demographic
Information
Date of birth: / / (MM/DD/YYYY)
Country of usual residence: If usual resident of U.S., county of residence:
Race:
(check all that apply) White Asian American
Indian/Alaska
Native Black
Native Hawaiian/Other Pacific Islander
Ethnicity: Hispanic
or
Latino Not
Hispanic or
Latino
Sex: Male Female
Symptoms,
Clinical Course, Treatment, Testing, and Outcome
What date did symptoms associated with this illness start? / / (MM/DD/YYYY)
During
this illness, did the patient experience any of the
following?
Symptom |
Symptom Present? |
Symptom |
Symptom Present? |
||||||
Fever (highest temp oF) |
Yes No Unk |
Shortness of breath |
Yes |
No |
Unk |
||||
If fever present, date of onset |
|
/ |
|
/ |
(MM/DD/YYYY) |
Vomiting |
Yes |
No |
Unk |
Felt feverish |
Yes No Unk |
Diarrhea |
Yes |
No |
Unk |
||||
If felt feverish, date of onset |
/ |
|
/ |
|
(MM/DD/YYYY) |
Eye infection/redness |
Yes |
No |
Unk |
Cough |
Yes No Unk |
Rash |
Yes |
No |
Unk |
||||
Sore Throat |
Yes No Unk |
Fatigue |
Yes |
No |
Unk |
||||
Muscle aches |
Yes No Unk |
Seizures |
Yes |
No |
Unk |
||||
Headache |
Yes No Unk |
Other, specify |
Yes |
No |
Unk |
Does
the patient still have
symptoms?
Yes (skip to
Q.13) No Unknown (skip to
Q.13)
When did the patient feel back to normal? / / (MM/DD/YYYY)
Did the patient receive any medical care for the illness?
Yes No (skip to
Q.30) Unknown (skip to
Q.30)
Where and on what date did the patient seek care (check all that apply)?
Doctor’s office
date: / / (MM/DD/YYYY) Emergency
room date:
/ / (MM/DD/YYYY)
Urgent care
clinic date:
/ / (MM/DD/YYYY) Health department
date: / / (MM/DD/YYYY) Other date:
/ / (MM/DD/YYYY) Unknown
Was the patient hospitalized for the illness?
Yes No
(skip to
Q.24) Unknown (skip to
Q.24)
Date(s) of hospital admission? First admission date: / / (MM/DD/YYYY) Second admission date: / / (MM/DD/YYYY)
Was the patient admitted to an intensive care unit (ICU)?
Yes No
(skip to
Q.19) Unknown (skip to
Q.19)
Date of ICU admission: / / (MM/DD/YYYY) Date of ICU discharge: / / (MM/DD/YYYY)
Did
the patient receive mechanical ventilation / have a breathing tube?
Yes No (skip to Q.21) Unknown (skip to Q.21)
For how many days did the patient receive mechanical ventilation or have a breathing tube? days
Was the patient discharged?
Yes No (skip to
Q.24) Unknown (skip to
Q.24)
Date(s) of hospital discharge? First discharge date: / / (MM/DD/YYYY) Second discharge date: / / (MM/DD/YYYY)
Where was the patient discharged?
Home Nursing
facility/rehab Hospice Other Unknown
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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0004).
Did the patient have a new abnormality on chest x-ray or CT scan?
No,
x-ray or scan was
normal Yes, x-ray or scan detected
new abnormality No,
chest x-ray or CT scan not
performed Unknown
Did
the patient receive a diagnosis of pneumonia? Yes No Unknown
Did
the patient receive a diagnosis of
ARDS?
Yes No Unknown
Did
the patient have leukopenia (white blood cell count <5000
leukocytes/mm3)
associated with this illness? Normal Abnormal Test
not
performed Unknown
Did
the patient have lymphopenia (total lymphocytes <800/mm3
or lymphocytes
<15% of WBC) associated with this illness? Normal Abnormal Test
not
performed Unknown
Did
the patient have thrombocytopenia (total platelets <150,000/mm3)
associated with this illness? Normal Abnormal Test
not
performed Unknown
Did
the patient experience any other complications as a result of
this
illness? Yes
(please
describe
below) No Unknown
Did the patient receive influenza antiviral medications prior to becoming ill (within 2 weeks) or after becoming ill? Yes, (please complete table below) No Unknown
Drug |
Start date (MM/DD/YYYY) |
End date (MM/DD/YYYY) |
Total number of days receiving antivirals |
Dosage (if known) |
Oseltamivir (Tamiflu) |
|
|
|
mg |
Zanamivir (Relenza) |
|
|
|
mg |
Peramivir (Rapivab) |
|
|
|
mg |
Other influenza antiviral |
|
|
|
mg |
Did
the patient die as a result of this
illness?
Influenza
Testing
When was the specimen collected that indicated novel influenza A virus infection tested by Reverse Transcription-Polymerase Chain Reaction (RT-
PCR)? / / (MM/DD/YYYY)
Where
was the
specimen
collected? Doctor’s
office Hospital Emergency
room Urgent
care
clinic Health
department
Other Unknown
Was
a rapid influenza diagnostic test (RIDT) used on any respiratory
specimens
collected?
Yes No (skip to Q.39) Unknown (skip to Q.39)
When was the RIDT specimen collected? / / (MM/DD/YYYY)
What
was
the
result? Influenza
A Influenza
B Influenza
A/B (type
not
distinguished)
Negative Other
Medical
History -- Past Medical History and Vaccination Status
Does the patient have any of the following chronic medical conditions? Please specify ALL conditions that qualify.
a. |
Asthma/reactive airway disease |
Yes |
No |
Unknown |
|
b. |
Other chronic lung disease |
Yes |
No |
Unknown |
(If YES, specify) |
c. |
Chronic heart or circulatory disease |
Yes |
No |
Unknown |
(If YES, specify) |
d. |
Diabetes mellitus |
Yes |
No |
Unknown |
(If YES, specify) |
e. |
Kidney or renal disease |
Yes |
No |
Unknown |
(If YES, specify) |
f. |
Non-cancer immunosuppressive condition |
Yes |
No |
Unknown |
(If YES, specify) |
g. |
Cancer chemotherapy in past 12 months |
Yes |
No |
Unknown |
(If YES, specify) |
h. |
Neurologic/neurodevelopmental disorder |
Yes |
No |
Unknown |
(If YES, specify) |
i. |
Other chronic diseases |
Yes |
No |
Unknown |
(If YES, specify) |
Does
the
patient
frequently
use
a
stroller
or
wheelchair?
If
yes,
please
describe.
Yes No Unknown
Was patient pregnant or ≤6 weeks postpartum at illness onset?
Yes, pregnant (weeks pregnant at
onset) Yes, postpartum
(delivery date)
/ / (MM/DD/YYYY)
No Unknown
Does the patient currently smoke?
Yes
No Unknown
Was
the patient vaccinated against influenza in the past year? Yes No
(skip
to
Q.46) Unknown
(skip to
Q.46)
Month and year of influenza vaccination? Vaccination date 1: / (MM/YYYY) Vaccination date 2: / (MM/YYYY)
Epidemiologic
Risk Factors
In the 10 days prior to illness onset, did the patient travel outside of his/her usual area? Yes No (skip to Q.50) Unknown (skip to
Q.50)
When and where did the patient travel? Please describe details of the patient’s travel in the notes section at the end of the form.
Trip 1: Dates of travel: / / to / / Country State City/County
Trip 2: Dates of travel: / / to / / Country State City/County
Did the patient travel in a group (check all that apply)?
No,
travelled alone Yes,
with household
members Yes, with
non-household
members Unknown
Please describe the details of the trip
In the 10 days prior to illness onset, did the patient attend a public event where a large number of people were present (e.g., a sporting event, wedding, concert)? Yes No (skip to Q.52) Unknown (skip to Q.52)
Please
describe the event (include date and
location)
In the 10 days prior to illness onset, or at any time after illness onset, did the patient travel by means of public conveyance where others were present (e.g., public bus or train)? Yes No (skip to Q.54) Unknown (skip to Q.54)
Please
describe means and frequency of public
travel
In the 10 days prior to illness onset, did the patient have close contact with someone who travelled outside the United States? Yes No (skip to Q.56) Unknown (skip to Q.56)
Please
describe individual (including travel
location)
Risk
Factors – Animal and Animal Product Exposure
In the 10 days before becoming ill, did the patient attend an agricultural fair or event (e.g. show or auction)?
Yes
(specify name, if >1 fair, please describe in the
notes section
) No Unknown
In the 10 days before becoming ill, did the patient attend a live animal market?
Yes
(specify name. If >1 market, please describe in the
notes section
) No Unknown
(If the answers to Q.56 and Q.57 are both No or Unknown skip to Q.59.)
In
the
10
days
before
becoming
ill,
on
what
days
did
the
patient
attend
an
agricultural
fair/event
or
live
animal
market
(check
all
that
apply)? on the
day of
illness
onset 1 day
before
illness
onset 2 days
before
illness
onset 3 days
before illness
onset
4 days before illness onset 5 days before illness onset 6 days before illness onset 7 days before illness onset 8 days before illness onset 9 days before illness onset 10 days before illness onset
In the 10 days before becoming ill, did the patient have direct contact with any animals? Direct contact is defined as: handling, touching, or petting an animal. This could have been at your home or another home, at a pet store, petting zoo, retail store, school, daycare, or other location.
Yes No
(skip
to
Q.62) Unknown
(skip to
Q.62)
What type(s) of animals did the patient have direct contact with (check all that apply)?
Horses Cows Poultry/wild
birds Sheep Goats Pigs/hogs Other (1)
Other (2)
Other (3)
Other (4)
Where did the direct contact occur (check all that apply)?
Home Work Agricultural
fair or
event Live animal
market Petting
zoo Slaughterhouse/rendering facility
Other
In the 10 days before becoming ill, did the patient have any other exposure to (touch potentially contaminated surfaces, walk through an area containing or come within 6 feet of) any animals?
Yes No
(skip to
Q.65) Unknown (skip to
Q.65)
What type(s) of animals did the patient have this exposure to from Q.62 (e.g, touch potentially contaminated surfaces, walk through an area containing or come within 6 feet of ) (check all that apply)?
Horses Cows Poultry/wild
birds Sheep Goats Pigs/hogs Other
(1)
Other (2)
Other (3)
Other (4)
Where did this exposure occur (check all that apply)?
Home Work Agricultural
fair or
event Live animal
market Petting zoo Other
In the 10 days before becoming ill, did the patient have direct or any other contact with any animal exhibiting signs of illness?
Yes
(specify animal type and
location ) No Unknown
In the 10 days before becoming ill, did the patient have direct or any other contact with any animal confirmed to be influenza A positive?
Yes
(specify animal type and
location ) No Unknown
Yes
(specify influenza subtype (if known) ) No Unknown
Does
anyone in the household own, keep or care for livestock, poultry,
or farm animals (either at home or in the
workplace)?
Yes No (skip to Q.69) Unknown (skip to Q.69)
What type(s) of animals are owned, kept, or cared for by household members (check all that apply)?
Horses Cows Poultry/wild
birds Sheep Goats Pigs/hogs Other (1)
Other (2) Other (3) Other (4)
In the 10 days before becoming ill, did the patient drink any raw or unpasteurized milk from a cow or other animal sources, including drinking milk on the farm where it was produced or drinking milk from the “bulk tank”?
Yes
No Unknown Refused
(If yes ask sub-questions a through g, write in “Refused” if refused to answer or “NA” if question not applicable)
What type of milk (cow milk, goat milk, etc.), variety, and brand: ___________________________________ Unknown
What was the first date of consumption in the 10 days before becoming ill (MM-DD-YYY): ______________ Unknown
Where was the milk acquired (store name, farm name, herd share, etc.): __________________________ Unknown
What was the address, city, and state of acquisition (if not case’s home):________________________________________ Unknown
What was the product expiration/best by/best before date: __________________________________________ Unknown
What was the product lot number or code on the packaging:________________________________________ Unknown
Is
there any remaining product? Yes No Unknown
In the 10 days before becoming ill, did the patient consume any raw or unpasteurized milk products? (select all that apply):
Raw milk cheese Heavy raw cream Whole raw kefir Raw butter Raw yogurt Raw kefir pet food Raw milk pet food Other (specify):
Unknown Refused
(If yes ask sub-questions a through g, write in “Refused” if refused to answer or “NA” if question not applicable)
What was the type (cow milk, goat milk, etc.), variety, and brand: _____________________________________ Unknown
What was the consumption date (MM-DD-YYY): Unknown
Where was the milk product acquired (store name, farm name, herd share, etc.): __________________________ Unknown
What was the address, city, and state of acquisition (if not case’s home):_________________________________________ Unknown
What was the product expiration/best by/best before date: ____________________________________________ Unknown
What was the product lot number or code on the packaging:__________________________________________ Unknown
Is
there any remaining product? Yes No Unknown
Risk
Factors – Household, Occupational, Nosocomial, and Secondary
Spread
Does the patient reside in an institutional or group setting (e.g. nursing home, boarding school, college dormitory)? Yes (skip to Q.73) No Unknown (skip to Q.73)
How many people resided in the patient’s household(s) in the week before or after illness onset (excluding the patient)?
ID |
Household (HH) [“A” should be the patient’s primary household] |
Relation to patient (e.g. parent, brother, friend) |
Sex (M/F) |
Age |
Was HH member ill (fever or any respiratory symptom) +/– 7 days from case patient’s onset? |
If Yes, HH member’s date of illness onset |
1 |
A B C |
|
|
|
Y N U |
|
2 |
A B C |
|
|
|
Y N U |
|
3 |
A B C |
|
|
|
Y N U |
|
4 |
A B C |
|
|
|
Y N U |
|
5 |
A B C |
|
|
|
Y N U |
|
6 |
A B C |
|
|
|
Y N U |
|
In the 7 days before or after becoming ill, did the patient attend or work at a childcare facility?
Yes
(before becoming
ill) Yes (after becoming
ill) No (skip to
Q.75) Unknown (skip to
Q.75)
Approximately how many children are in the patient’s class or room at the childcare facility?
In the 7 days before or after becoming ill, did the patient attend or work at a school?
Yes
(before becoming
ill) Yes (after becoming
ill) No (skip to
Q.77) Unknown (skip to
Q.77)
Approximately how many students are in the patient’s class at the school?
In
the
7
days
before
or
after
the
patient
became
ill,
did
anyone
else
in
the
patient’s
household(s)
work
at
or
attend
a
childcare
facility
or
school? Yes No
(skip
to
Q.79) Unknown
(skip to
Q.79)
List ID numbers from Q.72 (the table above) for household members working at or attending a childcare facility or school:
Does the patient handle samples (animal or human) suspected of containing influenza virus in a laboratory or other setting? Yes No Unknown
In
the 7 days before or after becoming ill, did the patient work in or
volunteer at a healthcare facility or setting? Yes No (skip
to
Q.83) Unknown
(skip to
Q.83)
Specify healthcare facility job/role:
Physician Nurse Administration
staff Housekeeping Patient
transport Volunteer Other
Did
the patient have direct patient contact while working or
volunteering at a healthcare facility? Yes No Unknown
In
the 7 days before becoming ill, was the patient in a hospital for
any reason (i.e., visiting, working, or for treatment)?
Yes No Unknown
If yes, what were the dates? / / , / / City/Town
In
the 7 days before becoming ill, was the patient in a clinic or a
doctor’s office for any reason? Yes No Unknown
If yes, what were the dates? / / , / / City/Town
Does the patient know anyone other than a household member who had fever, respiratory symptoms like cough or sore throat, or another respiratory illness like pneumonia in the 7 days BEFORE the case patient’s illness onset?
ID |
Relationship to patient |
Sex (M/F) |
Age |
Date of illness onset |
Comments |
1 |
|
|
|
|
|
2 |
|
|
|
|
|
3 |
|
|
|
|
|
4 |
|
|
|
|
|
Does the patient know anyone other than a household member who had fever, respiratory symptoms like cough or sore throat, or another respiratory illness like pneumonia beginning AFTER the case patient’s illness onset?
Yes
(please list those ill after the case patient in the
table below) No Unknown
ID |
Relationship to patient |
Sex (M/F) |
Age |
Date of illness onset |
Comments |
1 |
|
|
|
|
|
2 |
|
|
|
|
|
3 |
|
|
|
|
|
4 |
|
|
|
|
|
Is the patient a contact of a confirmed or probable case of novel influenza A infection?
Yes
(please list patient’s confirmed or probable contacts in the
table below) No Unknown
Relationship to patient |
State Epi ID |
State Lab ID |
Case status |
Sex (M/F) |
Age |
Date of illness onset (MM/DD/YYYY) |
|
|
|
|
Confirmed |
Probable |
|
|
|
|
|
|
Confirmed |
Probable |
|
|
|
|
|
|
Confirmed |
Probable |
|
|
|
|
|
|
Confirmed |
Probable |
|
|
|
Any
additional comments or notes (e.g. travel details, names/dates of
fairs or live markets attended by case patient, dates of household
members fair attendance and location of fair, information about
other ill
contacts)?
Variant Module – complete only if confirmed case with a variant influenza virus (i.e. H1N1v, H1N2v, H3N2v)
In the 10 days before becoming ill, on what days did the patient have direct or any other exposure (touch or handle pigs or touch potentially contaminated surfaces, walk through an area containing, or come within 6 feet of any pigs/hogs) to pigs (check all that apply)?
on
the day of illness
onset 1 day before
illness onset 2
days before illness
onset 3 days before
illness onset 4
days before illness
onset 5 days before
illness onset 6
days before illness
onset 7 days before
illness onset
8 days before illness
onset 9 days before
illness onset 10
days before illness onset
What was the total number of days the patient reported direct or any other pig exposure ? days.
Please
describe animal exposure for all household members listed in Q.72 of
the main Novel A Case Report Form (please
use the same id for each person as in Q. 72 of the main
form).
ID |
If household (HH) member was ILL |
If HH member was NOT ILL |
|||||||
Did HH member have any pig/hog exposure ≤10 days before illness onset? |
Did HH member visit a live market or fair ≤10 days before illness onset? |
Did HH member have any pig/hog exposure or visit a live market visit ≤10 days before the case-patient’s illness onset? |
|||||||
1 |
Y |
N |
U |
Y |
N |
U |
Y |
N |
U |
2 |
Y |
N |
U |
Y |
N |
U |
Y |
N |
U |
3 |
Y |
N |
U |
Y |
N |
U |
Y |
N |
U |
4 |
Y |
N |
U |
Y |
N |
U |
Y |
N |
U |
5 |
Y |
N |
U |
Y |
N |
U |
Y |
N |
U |
6 |
Y |
N |
U |
Y |
N |
U |
Y |
N |
U |
In
the
10
days
before
becoming
ill,
did
the
patient
have
direct
or
any
other
exposure
(e.g.
caring
for,
speaking
with,
or
touching)
with
anyone
other than a household member who routinely has exposure with pigs/hogs?
Yes No Unknown
Please
describe the pig/hog exposure and fair attendance for individuals
listed in Q. 85 of the main Novel A Case Report
Form.
ID |
Any pig/hog exposure or fair attendance ≤10 days before his/her onset? |
Comments |
||
1 |
Y |
N |
U |
|
2 |
Y |
N |
U |
|
3 |
Y |
N |
U |
|
4 |
Y |
N |
U |
|
Please
describe
the
pig/hog
exposure
and
fair
attendance
of
individuals
listed
in
Q.
86
of
the
main
Novel
A
Case
Report
Form.
ID |
Any pig/hog exposure or fair attendance ≤10 days before his/her onset? |
Comments |
||
1 |
Y |
N |
U |
|
2 |
Y |
N |
U |
|
3 |
Y |
N |
U |
|
4 |
![]() Y |
N |
![]() U |
|
Notes:
|
|
|
Avian Module – complete only if confirmed case with an avian influenza virus (i.e. H5N1, H7N9)
Has the patient ever received an influenza H5N1 vaccination?
Yes
(Date: / / ) No Unknown
In the 10 days before becoming ill, did the patient have direct contact with poultry (chickens, turkeys, ducks, or geese, etc.)? Direct contact is defined as: handling, touching, or petting an animal. This could have been at the patient's home or another home, at a pet store, petting zoo, retail store, school, daycare, or other location.
Yes No
(skip to
Q.100) Unknown (skip to
Q.100)
Where did the direct contact with poultry occur (check all that apply)?
Home Commercial
poultry farm Agricultural
fair or
event Live animal
market Petting zoo
Veterinary
care Slaughterhouse/Rendering facility
Other
What type(s) of poultry did the patient have direct contact with (check all that apply)?
Chickens Turkeys Geese Pheasants Ducks Ostriches Emu
Pigeons Other
In the 10 days before becoming ill, did the patient have any other exposure (e.g., touch potentially contaminated surfaces, walk through an area containing or come within 6 feet of) to poultry?
Yes No
(skip to
Q.113) Unknown (skip to
Q.113)
Where did this exposure from Q.100 to poultry occur (check all that apply)?
Home Commercial
poultry farm Agricultural
fair or
event Live animal
market Petting zoo
Veterinary
care Slaughterhouse Other
What type(s) of poultry did the patient have this exposure to (check all that apply)?
Chickens Turkeys Geese Pheasants Ducks Ostriches Emus
Pigeons Other
Did
the patient clean any poultry pens/houses in the 10 days before
becoming
ill?
Yes No Unknown
Did
the patient feed or water any poultry in the 10 days before becoming
ill?
Yes No Unknown
Did the patient have direct contact with surfaces contaminated by bird or poultry feces or poultry parts (carcasses, internal organs, etc.) in the 10 days before becoming ill?
Yes No Unknown
Did the patient participate in the culling of any poultry flocks?
Yes No
(skip to
Q.109) Unknown (skip to
Q.109)
What measures did the patient use to protect himself/herself during the culling (check all that apply)?
None Facemask Respirators Hand
gloves Eye Protection Gowns Boots Unknown
Other
What percentage of time did the person participating in culling wear the items mentioned above while culling flocks (only ask about the items the exposed person mentioned in Q. 107)?
% Facemask % Respirators % Hand gloves % Eye protection % Gowns % Boots
% Other
In the 10 days before becoming ill, on what days did the patient have direct or any other exposure with birds or poultry (check all that apply)?
on
the day of illness
onset 1 day before
illness onset 2
days before illness
onset 3 days before
illness onset
4 days before illness onset 5 days before illness onset 6 days before illness onset 7 days before illness onset
8 days before illness onset 9 days before illness onset 10 days before illness onset
From Q.109, what was the total number of different days the patient reported direct or any other bird or poultry exposure? days
Did the patient report direct or any other exposure (direct or any other exposure or both) with any ill-appearing poultry in the 10 days before becoming ill?
Yes,
specify No Unknown
Did the patient report direct or any other exposure (direct, or any other exposure, or both) with dead poultry in the 10 days before becoming ill?
Yes,
specify
No Unknown
Avian Module continued– complete only if confirmed case with an avian influenza virus (i.e. H5N1, H7N9)
Were poultry raised on the patient’s property?
Yes No
(skip to
Q.121) Unknown (skip to
Q.121)
Where were the poultry kept (check all that apply)?
In patient’s basement
or garage Inside
patient’s house/living
space Open-air poultry pen or poultry
house
Enclosed
poultry pen or poultry
house Other enclosure/cage outside the
patient’s
house Other
What type(s) of poultry did the patient raise (check all that apply)? Please estimate the number of each type raised.
Chickens
# Turkeys # Geese # Pheasants # Ducks
# Ostriches # Emus # Pigeons # Other
#
Did
the patient’s household have any recent (within the past 30
days) ill-appearing poultry? Yes No Unknown
Did the patient’s household have any recent poultry die-offs?
Yes No
(skip to
Q.121) Unknown (skip to
Q.121)
Please indicate the percent of the flock that died. %
When did the die-off begin and end? Begin date: / / (MM/DD/YYYY) End date: / / (MM/DD/YYYY)
Was the flock culled?
Yes
(date / / MM/DD/YY) No Unknown
Did
the patient have exposure to any eggs from a private flock (i.e.,
not store bought or commercial) in the 10 days before becoming ill?
Yes No Unknown
Did
the patient consume raw or undercooked poultry in the 10 days before
becoming ill? Yes No Unknown
Does anyone else in the household own, keep or care for poultry in a location other than the patient’s property?
Yes,
specify No
Unknown
Were
there any recent reports of sick or dead poultry in the case
patient’s
area?
Yes,
specify
No Unknown
Were
captive wild birds kept at the patient’s
residence?
Yes
(describe) No Unknown
Did the patient visit any areas where wild/migratory birds (e.g. herons, gulls, falcons, wild ducks, geese, or swans) are present?
Yes,
specify location
No Unknown
In the 10 days before illness onset, did the patient have direct or any other exposure (touch or handle or touch potentially contaminated surfaces, walk through an area containing, or come within 6 feet of) to wild/migratory birds?
Yes No (skip to Q.132) Unknown (skip to Q.132)
In the 10 days before illness onset, did the patient have any direct contact (touch or handle) with any wild/migratory birds?
Yes,
specify type of
bird(s) No Unknown
In the 10 days before becoming ill, did the patient have any other exposure to (touch potentially contaminated surfaces, walk through an area containing, or come within 6 feet of) any wild/migratory birds?
Yes,
specify type of
bird(s)
No Unknown
Were
any
of
the
wild/migratory
birds
that
the
patient
had
direct or
any other
contact
with
sick
or
dying?
Yes,
specify
No
Unknown
Avian Module continued– complete only if confirmed case with an avian influenza virus (i.e. H5N1, H7N9)
In the 10 days before becoming ill, on what days did the patient have direct or any other exposure (touch or handle or touch potentially contaminated surfaces, walk through an area containing, or come within 6 feet of) with wild birds (check all that apply)?
In the 10 days before becoming ill, did the patient have direct or any other exposure with birds other than poultry or wild/migratory birds?
Yes,
specify type of
bird(s) No (skip
to Q.135) Unknown
(skip to Q135.)
Were any of these birds that the patient had direct or any other exposure with sick or dying?
Yes,
specify No Unknown
In the 10 days before becoming ill, on what days did the patient have direct or any other exposure with these birds (check all that apply)?
135. In the 10 days before becoming ill, did the patient have direct contact (touch or handle) with livestock (cattle, goats, sheep, pigs, etc.)?
Yes No
(skip to
Q.138) Unknown (skip to
Q.138)
136. Where did the direct contact with livestock occur (check all that apply)?
Home Commercial
farm Agricultural fair or
event Live animal
market Petting
zoo Veterinary care
Slaughterhouse Other
137. What type(s) of livestock did the patient have direct contact with (check all that apply)?
Cattle Sheep Goats Other
138. In the 10 days before becoming ill, did the patient have any other exposure to (e.g., touch potentially contaminated surfaces, walk through an area containing, or come within 6 feet of) livestock?
Yes No
(skip to
Q.141) Unknown (skip to
Q.141)
139.
Where did this
exposure from Q.138
to livestock occur (check all that
apply)?
Home Commercial
farm Agricultural fair
or event
Live animal
market Petting
zoo Veterinary
care Slaughterhouse/rendering facility Other
140. What type(s) of livestock did the patient have this exposure to from Q.138 (check all that apply)?
Cattle Sheep Goats Other
141. Did the patient conduct any of the following activities in the 10 days before becoming ill (check all that apply)?
Work
at a farm or facility where live animals are present Touch,
handle, or otherwise interact with ill livestock (cattle, goats,
sheep)
Touch,
handle, or otherwise interact with ill wild animals Drink
or handle raw or unpasteurized milk
Consume
or handle raw or unpasteurized milk products (cheese, cream, kefir,
etc.) Work in a maternity or reproductive area of a farm
Handle
or clean up animal stool or manure
Use a pressure washer or broom in an area
contaminated by animal manure or milk
Operate
or clean automated milking equipment Perform manual milking
of animals
142.
Did the patient clean any livestock pens in the 10 days before
becoming
ill?
Yes No Unknown
143.
Did the patient feed or water any livestock in the 10 days before
becoming ill?
Yes No Unknown
144. Did the patient have direct contact with surfaces contaminated by livestock, livestock manure, livestock milk, or livestock parts (carcasses, internal organs, reproductive tissues, etc.) in the 10 days before becoming ill?
Yes No Unknown
145. What measures did the patient use to protect himself/herself when exposed to livestock (check all that apply)?
None Facemask Respirators
Hand gloves
Eye Protection Gowns Boots Unknown
Other
146. What percentage of time did the person wear the items mentioned above while exposed to livestock (only ask about the items the exposed person mentioned in Q. 146)?
% Facemask % Respirators % Hand gloves % Eye protection % Gowns % Boots
% Other
147. In the 10 days before becoming ill, on what days did the patient have direct or any other exposure (touch or handle or touch potentially contaminated surfaces, walk through an area containing, or come within 6 feet of) to livestock (check all that apply)?
on
the day of illness
onset 1 day before
illness onset
2 days before illness
onset 3 days before
illness onset
4 days before illness onset 5 days before illness onset 6 days before illness onset 7 days before illness onset
8 days before illness onset 9 days before illness onset 10 days before illness onset
148. Did the patient report direct or any other exposure to any livestock that appeared ill in the 10 days before becoming ill?
Yes,
specify No Unknown
149. Did the patient report direct or any other exposure to dead livestock in the 10 days before becoming ill?
Yes,
specify No Unknown
Please describe bird/poultry/livestock exposure for all household members listed in Q.72 of the main Novel A Case Report Form (please use the same ID as in Q.72).
ID |
If HH member was ILL |
If HH member was NOT ILL |
|||||||
|
Did HH member have any bird exposure ≤10 days before his/her onset? |
Did HH member visit a live market ≤10 days before his/her onset? |
Did HH member have any bird exposure or visit a live market visit ≤10 days before the case-patient’s illness onset? |
||||||
1 |
Y |
N |
U |
Y |
N |
U |
Y |
N |
U |
2 |
Y |
N |
U |
Y |
N |
U |
Y |
N |
U |
3 |
Y |
N |
U |
Y |
N |
U |
Y |
N |
U |
4 |
Y |
N |
U |
Y |
N |
U |
Y |
N |
U |
5 |
Y |
N |
U |
Y |
N |
U |
Y |
N |
U |
6 |
Y |
N |
U |
Y |
N |
U |
Y |
N |
U |
Please
describe the bird exposure and live market visits for individuals
listed in Q.72 of the main Novel A Case Report
Form.
ID |
Any bird exposure or live market visits ≤10 days before his/her onset? |
Comments |
1 |
Y N U |
|
2 |
Y N U |
|
3 |
Y N U |
|
4 |
Y N U |
|
Please
describe the bird exposure and live market visits of individuals
listed in Q.72 of the main Novel A Case Report
Form.
ID |
Any bird exposure or live market visits ≤10 days before his/her onset? |
Comments |
1 |
Y N U |
|
2 |
Y N U |
|
3 |
Y N U |
|
4 |
Y N U |
|
In
the 7 days before becoming ill, did the patient have direct or other
exposure (e.g., caring for, speaking with, or touching) with anyone
other than a
household member who
routinely has exposure to
birds?
Yes No Unknown
Notes:
|
|
|
|
|
|
|
|
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |