Pandemic Influenza Plan - Questar III

NYSDOH Novel Influenza Case Report Form
State case ID: ___________________ Appendix 2-B
Staphylococcus aureus, methicillin resistant
____________________________________________________________
Staphylococcus aureus, sensitivity not done
____________________________________________________________
Other (specify)___________________________ ______________________________________________________________
3. Is a bacterial isolate available for further testing by CDC?.................................... ….. Yes No Unknown
Non-Influenza and Non-bacterial infections (viruses and fungal infections)
1. Was there laboratory testing evidence for a viral infection (not influenza) or fungal infection? Yes No Unknown
2. If YES, please specify what virus or fungal infection and specimen source: ___________________________________________
Epidemiologic Risk Factors
TRAVEL EXPOSURES:
1a. In the 10 days prior to illness onset, did the patient travel to a foreign or domestic area with
documented or suspected recent/previous novel influenza activity?
If YES,
Country: _____________________________________________________________________
Arrival Date: ______/ ______ / _________ Departure Date: ______/ ______ / _________
1b. Did the patient come within 3 feet of any live poultry or domesticated birds (e.g., visited a
poultry farm, a household raising poultry, or a bird market)?
1c. Did the patient touch any recently butchered poultry?
1d. Did the patient visit or stay in the same household with anyone with pneumonia or severe flulike
illness?
1e. Did the patient visit or stay in the same household with a suspected human novel influenza
case?
1f. Did the patient visit or stay in the same household with a known human novel influenza case?
NON-TRAVEL EXPOSURE:
For patients whom did not travel to an affected area, in the 10 days prior to onset, did the patient
have contact with a suspect or confirmed human novel influenza case?
If yes, Did the patient visit or stay in the same household as the case?
Influenza Vaccine and Antiviral History
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No Unknown
No Unknown
No Unknown
No Unknown
No Unknown
No Unknown
No Unknown
No Unknown
1. Did the patient receive any influenza vaccine during the current season (before illness)? Yes No Unknown
2. If YES, please specify influenza vaccine received before illness onset: Trivalent inactivated influenza vaccine (TIV) [injected]
Live-attenuated influenza vaccine (LAIV) [nasal spray]
3. If YES, how many doses did the patient receive during the current season (before illness)? 1 dose 2 doses
4. If YES, specify influenza vaccination dates:
Dose 1: _______/ _______/ ________ < 14 days prior to illness > 14 days prior to illness
Dose 2: _______/ _______/ ________ < 14 days prior to illness > 14 days prior to illness
5. Did the patient ever receive influenza vaccine in a previous season?............................................. Yes No Unknown
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