Form 0920-0009 Acute Flaccid Myelitis: Patient Summary Form

[NIOSH] National Disease Surveillance Program

D4. AFM_form_12.18.25_clean

Att D-4_Acute Flaccid Myelitis

OMB: 0920-0009

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Acute Flaccid Myelitis: Patient Summary Form
FOR LOCAL USE ONLY
Name of person completing form: ______________________________________________________ State assigned patient ID: ____________________________
Affiliation__________________________________________ Phone: ____________________________Email: __________________________________________
Name of physician who can provide additional clinical/lab information, if needed ___________________________________________________________________
Affiliation_____________________________________________ Phone: ___________________________ Email: ________________________________________
Name of main hospital that provided patient’s care: ________________________________________________ State: _____ County: ______________________
-------------------------------------------------------------DETACH and transmit only lower portion to AFMInfo@cdc.gov if sending to CDC-------------------------------------------------------------

Acute Flaccid Myelitis: Patient Summary Form
Please send the following information along with the patient summary form:  MRI report

Form Approved
OMB No. 0920-0009
Exp Date: 01/31/2026

 MRI images  Neurology consult note

1. Today’s date__ __/__ __/__ __ __ __ (mm/dd/yyyy)

2. State assigned patient ID: ______________________________

3. Sex:  M

Residence: 5. State_______ 6. County______________________

F 4. Date of birth __ __/ __ __/ __ __ __ __

7. Race: American Indian or Alaska Native
 Middle Eastern or North African

Asian
Black or African American
Native Hawaiian or Other Pacific Islander

Hispanic or Latino
White
(check all that apply)

8. Date of onset of limb weakness __ __/__ __/__ __ __ __ (mm/dd/yyyy)
9. Was patient admitted to a hospital? yes

no unknown

10.Date of admission to first hospital__ __/__ __/__ __ __ __

11.Date of discharge from last hospital__ __/__ __/__ __ __ __(or  still hospitalized at time of form submission)
12. Did the patient die from this illness? yes

no unknown

13. If yes, date of death__ __/__ __/__ __ __

SIGNS/SYMPTOMS/CONDITION:
Right Arm
14. Weakness? [indicate yes(y), no (n), unknown (u) for each limb]
14a. Tone in affected limb(s) [flaccid, spastic, normal for each limb]

Y
N
U
 flaccid
 spastic
 normal
 unknown
Yes
No
Unk

15. Was patient admitted to ICU?
In the 4-weeks BEFORE onset of limb weakness, did patient:

Left Arm

Right Leg

Y
N
U
 flaccid
 spastic
 normal
 unknown

Left Leg
Y
N
U
 flaccid
 spastic
 normal
 unknown

16. If yes, admit date: __ __/__ __/__ __ __ __
Yes

Unk

17. Have a respiratory illness?
19. Have a gastrointestinal illness (e.g., diarrhea or vomiting)?
21. Have a fever, measured by parent or provider ≥38.0°C/100.4°F?
23. Have pain in neck or back?

18. If yes, onset date
20. If yes, onset date
22. If yes, onset date
24. If yes, onset date

25. At onset of limb weakness, does patient have any underlying
illnesses?

26. If yes, list:

__ __/__ __/__ __ __ __
__ __/__ __/ __ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __

Travel history:
27. Did the patient travel outside of the US in the 30 days before the onset of limb weakness?

 yes

 no

 unknown

27a. If yes, list country/countries
Polio vaccination history:
28. Has the patient received polio vaccine?
28a. How many doses of inactivated polio vaccine (IPV) are documented to have been received by the
patient before the onset of limb weakness?

 yes

 no

 unknown

doses

 unknown

28b. How many doses of oral polio vaccine (OPV) are documented to have been received by the patient
before the onset of limb weakness?

doses

 unknown

28c. How many doses of unknown type of polio vaccine are documented to have been received by the
patient before the onset of limb weakness?

doses

 unknown

Public reporting burden of this collection of information is estimated to average 12 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 estima te 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.

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Magnetic Resonance Imaging:
29. Was MRI of spinal cord performed?  yes
 no  unknown
30. If yes, date of spine MRI: __ __/__ __/__ __ __ __
31. Did the spinal MRI show a lesion in at least some spinal cord gray matter?  yes
 no  unknown
32. Was MRI of brain performed?
 yes
 no  unknown
33. If yes, date of brain MRI: __ __/__ __/__ __ __ __
CSF examination: 34. Was a lumbar puncture performed?  yes
 no  unknown
If yes, complete 34 (a,b) (If more than 2 CSF examinations, list the first 2 performed)
Date of
lumbar
puncture

WBC/mm3

%
neutrophils

%
lymphocytes

%
monocytes

%
eosinophils

RBC/mm3

Glucose
mg/dl

Protein
mg/dl

34a. CSF from LP1
34b. CSF from LP2

Public reporting burden of this collection of information is estimated to average 20 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 estima te 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.

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At time of 60 day follow-up please collect and send the following information: for confirmed and probable cases
 Discharge summary  History and physical (H&P)  Neurology consult notes  EMG report (if done)
 Infectious disease consult notes (if available)  Vaccine registry record  Diagnostic laboratory reports

Acute Flaccid Myelitis Outcome – complete follow-up for all reported persons under investigation (PUI) at 60 days after
onset of limb weakness.
35. Date of follow-up: __ __/__ __/__ __ __ __ (mm/dd/yyyy)
36. Impairment:

 None

 Minor (any minor involvement)  Significant (≤2 extremities, major involvement)
 Severe (≥3 extremities and respiratory involvement)  Death  Unknown
36a. Date of death: __ __/__ __/__ __ __ __ (mm/dd/yyyy)

37. Physical condition (includes cardiovascular, gastrointestinal, urologic, endocrine as well as neurologic disorders):
i.
ii.
iii.
iv.

Medical problems sufficiently stable that medical or nursing monitoring is not required more often than 3-month intervals
Medical or nurse monitoring is needed more often than 3-month intervals but not each week.
Medical problems are sufficiently unstable as to require medical and/or nursing attention at least weekly.
Medical problems require intensive medical and/or nursing attention at least daily (excluding personal care assistance)

38. Upper limb functions: Self-care activities (drink/feed, dress upper/lower, brace/prosthesis, groom, wash, perineal care) dependent mainly upon
upper limb function:
i.
ii.
iii.
iv.

Age-appropriate independence in self-care without impairment of upper limbs
Age-appropriate independence in self-care with some impairment of upper limbs
Dependent upon assistance in self-care with or without impairment of upper limbs.
Dependent totally in self-care with marked impairment of upper limbs.

39. Lower limb functions: Mobility (walk, stairs, wheelchair, transfer chair/toilet/tub or shower) dependent mainly upon lower limb function:
i.
ii.
iii.
iv.

Independent in mobility without impairment of lower limbs
Independent of mobility with some impairment of lower limbs, such as needing ambulatory aids, a brace or prosthesis
Dependent upon assistance or supervision in mobility with or without impairment of lower limbs.
Dependant totally in mobility with marked impairment of lower limbs.

40. Sensory components: Relating to communication (speech and hearing) and vision:
i.
ii.
iii.
iv.

Age-appropriate independence in communication and vision without impairment
Age-appropriate independence in communication and vision with some impairment such as mild dysarthria, mild aphasia or need for
eyeglasses or hearing aid.
Dependent upon assistance, an interpreter, or supervision in communication or vision
Dependent totally in communication or vision

41. Excretory functions (bladder and bowel control, age-appropriate):
i.
ii.
iii.
iv.

Complete voluntary control of bladder and bowel sphincters
Control of sphincters allows normal social activities despite urgency or need for catheter, appliance, suppositories, etc.
Dependent upon assistance in sphincter management
Frequent wetting or soiling from bowel or bladder incontinence

42. Support factors:
i.
ii.
iii.
iv.

Able to fulfil usual age-appropriate roles and perform customary tasks
Must make some modifications in usual age-appropriate roles and performance of customary tasks
Dependent upon assistance, supervision, and encouragement from an adult due to any of the above considerations
Dependent upon long-term institutional care (chronic hospitalization, residential rehabilitation, etc. Excluding time-limited hospitalization
for specific evaluation or treatment)

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Acute Flaccid Myelitis case definition
(https://cdn.ymaws.com/www.cste.org/resource/resmgr/ps/ps2021/21-ID-02_AFM.pdf)
Clinical Criteria
An illness with onset of acute flaccid* limb weakness AND
Absence of a clear alternative diagnosis attributable to a nationally notifiable condition.
* Low muscle tone, limp, hanging loosely, not spastic or contracted.

Confirmatory laboratory/imaging evidence:
MRI showing spinal cord lesion with predominant gray matter involvement* and spanning one or more vertebral segments, AND
Excluding persons with gray matter lesions in the spinal cord resulting from physician diagnosed malignancy, vascular disease, or
anatomic abnormalities.
Presumptive laboratory/imaging evidence:
MRI showing spinal cord lesion where gray matter involvement* is present but predominance cannot be determined, AND
Excluding persons with gray matter lesions in the spinal cord resulting from physician diagnosed malignancy, vascular disease, or
anatomic abnormalities.
Supportive laboratory/imaging evidence:
MRI showing a spinal cord lesion in at least some gray matter* and spanning one or more vertebral segments, AND
Excluding persons with gray matter lesions in the spinal cord resulting from physician diagnosed malignancy, vascular disease, or
anatomic abnormalities.
* Spinal cord lesions may not be present on initial MRI; a negative or normal MRI performed within the first 72 hours after onset of limb weakness does not rule out
AFM. Terms in the spinal cord MRI report such as “affecting mostly gray matter,” “affecting the anterior horn or anterior horn cells,” “affecting the central cord,”
“anterior myelitis,” or “poliomyelitis” would all be consistent with this terminology.

Other classification criteria
Autopsy findings that include histopathologic evidence of inflammation largely involving the anterior horn of the spinal cord spanning
one or more vertebral segments.
Vital Records Criteria
Any person whose death certificate lists acute flaccid myelitis as a cause of death or a condition contributing to death.
Case Classification
Confirmed:
Meets clinical criteria with confirmatory laboratory/imaging evidence, OR
Meets other classification criteria.
Probable:
Meets clinical criteria with presumptive laboratory/imaging evidence.
Suspect:
Meets clinical criteria with supportive laboratory/imaging evidence, AND
Available information is insufficient to classify case as probable or confirmed.

Acute Flaccid Myelitis specimen collection information
(https://www.cdc.gov/acute-flaccid-myelitis/hcp/specimen-collection.html)
Acute Flaccid Myelitis job aid
(https://www.cdc.gov/acute-flaccid-myelitis/downloads/job-aid-for-clinicians-508.pdf)

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Version 7.2 September 1, 2022

File Type	application/pdf
File Title	Acute Flaccid Myelitis Patient Summary Form
Subject	acute flaccid myelitis (AFM) patient summary form
Author	CDC/NCIRD
File Modified	2025-12-18
File Created	2025-12-18