"CDC Listeria Initiative Case Report Form"

CDC Listeria Initiative Case Report Form is a 13-page legal document that was released by the U.S. Department of Health and Human Services - Centers for Disease Control and Prevention and used nation-wide.

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U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION
CDC Listeria Initiative
Case Report Form
Version 2.0
Please complete this questionnaire for all laboratory-confirmed listeriosis cases.
Instructions are available in a separate two-page document.
Please remove this page before submitting form to CDC
State public health laboratory isolate ID:
_______________________________________________________________
Patient’s name: _________________________________
Date of Birth:
/
/
Address: ___________________________________________________________________________
City: _______________________________ State: ___ ___ Zip: ___ ___ ___ ___ ___
Phone numbers: (h) ____________________
(w) _____________________
(m) ________________________
Hospital: _____________________________
Hospital: _____________________________ (if >1 hospital)
Hospital contact: _________________________________
Hospital contact: _________________________________
Phone: ___________________________
Phone: ___________________________
If surrogate interview:
Interviewee name: ___________________________________
Interviewee phone number(s): ____________________________
_____________________________
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/ASTSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia, 30329; ATTN: PRA (0920-0728).
Form Approved - OMB No. 0920-0728
U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION
CDC Listeria Initiative
Case Report Form
Version 2.0
Please complete this questionnaire for all laboratory-confirmed listeriosis cases.
Instructions are available in a separate two-page document.
Please remove this page before submitting form to CDC
State public health laboratory isolate ID:
_______________________________________________________________
Patient’s name: _________________________________
Date of Birth:
/
/
Address: ___________________________________________________________________________
City: _______________________________ State: ___ ___ Zip: ___ ___ ___ ___ ___
Phone numbers: (h) ____________________
(w) _____________________
(m) ________________________
Hospital: _____________________________
Hospital: _____________________________ (if >1 hospital)
Hospital contact: _________________________________
Hospital contact: _________________________________
Phone: ___________________________
Phone: ___________________________
If surrogate interview:
Interviewee name: ___________________________________
Interviewee phone number(s): ____________________________
_____________________________
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/ASTSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia, 30329; ATTN: PRA (0920-0728).
Form Approved - OMB No. 0920-0728
U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION
Log of Attempts to Call Patient or Surrogate (Optional)
(This page is for health department use only; please remove it before submitting form to CDC)
Last Name: _________________________
First Name: __________________________
Date
Time
Caller
Results*
Comments** Plan
First initial & last name
(May include more than one)
__ _____________ _______
____
___________________
Call 1
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 2
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 3
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 4
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 5
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 6
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 7
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 8
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 9
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 10
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 11
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 12
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 13
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 14
__ / __ / ____
___:___
__ _____________ _______
____
___________________
Call 15
__ / __ / ____
___:___
**Key for Comments:
1 Interviewed with standard questionnaire
*Key for Results:
2 Called back for more information
1 Left message with person
3 Interviewed with supplemental questionnaire
2 Left message on voicemail
4 Language barrier, indicate plan
3 Did not leave message
5 No answer
6 Phone not in service, indicate plan
7 Refused
CDC Listeria Initiative Case Report Form
PulseNet ID or state public health lab isolate ID ____________________________
State epi case ID ___________________
Local epi case ID ____________________
Date form completed:
/
/
FoodNet ID (if applicable) _______________________________
NNDSS ID (if available) ___ ___ ___ ___ ___
Name of interviewer
first name
last name
Was the isolate sent to public health laboratory? £ Yes £ No £ Unknown
If No, why not, and could it still be obtained? ________________________
BOX 1: Case-patient demographic data
State of residence ___ ___
County _______________
Age _____ (if pregnancy-associated, use age of mother)
Sex £ Male £ Female £ Unknown
Ethnicity: Is the case-patient of Hispanic, Latino, or Spanish origin? (one or more categories may be selected)
£ Yes ----------------------------------------------------> If yes:
£ Mexican, Mexican American, Chicano
£ Another Hispanic, Latino, or Spanish origin (specify)
£ No
£ Puerto Rican
______________________
£ Unknown
£ Cuban
£ Unknown Hispanic ancestry/declined to specify
£ Declined to answer
Race (One or more categories may be selected)
£ African American/Black
£ Asian (specify)
£ White (specify)
£ Asian Indian
£ Middle Eastern/North African
£ Native American Indian or Alaska Native
£ Chinese
£ Not Middle Eastern/North African
£ Native Hawaiian or other Pacific Islander (specify)
£ Filipino
£ Unknown
£ Native Hawaiian
£ Japanese
£ Guamanian or Chamorro
£ Other (specify) _____________________
£ Korean
£ Samoan
£ Vietnamese
£ Declined to answer
£ Other Pacific Islander
£ Other Asian (specify) _________________
BOX 2: Is the Listeria case associated with pregnancy? (Illness in pregnant woman, fetus, or infants ≤60 days old)
£ Yes If yes, skip to Box 4.
£ No
£ Unknown
BOX 3: Cases not associated with pregnancy (Illness in non-pregnant adults and children >60 days old)
Type(s) of specimen(s) that grew Listeria
Specimen collection date
State public health lab isolate ID #
(check all that apply)
(mm/dd/yyyy)
(Important: must have at least one, if available)
£ Blood
____/____/____
£ CSF
____/____/____
£ Other (specify)
____/____/____
____/____/____
£ Other (specify)
Did patient have any of the following type(s) of illnesses related to the Listeria infection? (check all that apply)
£ Bloodstream infection/sepsis £ Meningitis
£ Meningoencephalitis £ Brain abscess £ Rhombencephalitis £ Peritonitis £ Pneumonia £ Wound infection
£ Joint infection/septic arthritis £ Bone infection/osteomyelitis £ Unknown £ Other (specify) _______________________________________
Was patient hospitalized for listeriosis? £ Yes £ No £ Unknown
If yes: Admit date:
/
/
Discharge date:
/
/
£ Still hospitalized as of:
/
/
Patient’s outcome: £ Survived £ Died £ Unknown
Date of death:
/
/
If died: Was listeriosis or Listeria infection listed on death certificate? £ Yes £ No £ Unknown
If survived: Last known date alive?
/
/
BOX 4: Cases associated with pregnancy (Illness in pregnant woman, fetus, or infants ≤60 days old)
Type(s) of specimen(s) that grew Listeria
Specimen collection date
State public health lab isolate ID #
(check all that apply)
(
/
/
)
(Important: must have at least one, if available)
mm
dd
yyyy
£ Blood from mother
____/____/____
£ Blood from infant
____/____/____
£ CSF from mother
____/____/____
£ CSF from infant
____/____/____
£ Placenta
____/____/____
£ Amniotic fluid
____/____/____
£ Fetal tissue
____/____/____
£ Other (specify)
____/____/____
£ Other (specify)
____/____/____
3
CDC Listeria Initiative Case Report Form
PulseNet ID or state public health lab isolate ID ____________________________
Outcome of pregnancy
Weeks of
Date
Outcome of pregnancy
Weeks of
Date
(single gestation or twin 1) (check one)
gestation
(mm/dd/yyyy)
(twin 2) (check one)
gestation
(mm/dd/yyyy)
____/____/____
____/____/____
£ Still pregnant
£ Still pregnant
£ Delivery (live birth)
£ Delivery (live birth)
£ Vaginal delivery
£ Vaginal delivery
____/____/____
____/____/____
£ C-section
£ C-section
£ Unknown delivery type
£ Unknown delivery type
£ Fetal death (miscarriage or stillbirth)
____/____/____
£ Fetal death (miscarriage or stillbirth)
____/____/____
____/____/____
____/____/____
£ Other (specify)
£ Other (specify)
Type(s) of illness in mother
Type(s) of illness in infant (twin 1)
Type(s) of illness in infant 2 (twin 2)
(check all that apply)
(check all that apply)
(check all that apply)
£ Fever
£ Bacteremia/sepsis
£ Bacteremia/sepsis
£ Bacteremia/sepsis
£ Meningitis
£ Meningitis
£ Meningitis
£ Pneumonia
£ Pneumonia
£ Gastroenteritis
£ None
£ None
£ Amnionitis
£ Other (specify)____________
£ Other (specify)_____________
£ Non-specific “flu-like” illness
£ Unknown
£ Unknown
£ None
£ Other (specify)___________________________
£ Unknown
Was mother hospitalized for listeriosis?
Where was the infant (twin 1) delivered?
Where was infant 2 (twin 2) delivered?
£ Yes If yes:
£ Hospital:
£ Hospital:
Admit or birth date:
/
/
Admit or birth date:
/
/
Admit or birth date:
/
/
Discharge date:
/
/
Discharge date:
/
/
Discharge date:
/
/
£ Still hospitalized
£ Still hospitalized
£ Still hospitalized
Hospital name: ___________________________
Hospital name: __________________________
Hospital name: __________________________
£ No
£ Home
£ Home
£ Unknown
£ Other (specify) _________________________
£ Other (specify) __________________________
£ Unknown
£ Unknown
Was the infant (twin 1) hospitalized for listeriosis? (may
Was infant 2 (twin 2) hospitalized for listeriosis? (may
include above dates)
include above dates)
£ Yes If yes:
£ Yes If yes:
Admit or birth date:
/
/
Admit or birth date:
/
/
Discharge date:
/
/
Discharge date:
/
/
£ Still hospitalized
£ Still hospitalized
£ No
£ No
£ Unknown
£ Unknown
Mother’s outcome
Infant 1’s (twin 1’s) outcome
Infant’s 2’s (twin 2’s) outcome
£ Survived
£ Survived
£ Survived
£ Died
£ Died
£ Died
£ Unknown
£ Unknown
£ Unknown
If survived: Last known date alive?
If survived: Last known date alive?
If survived: Last known date alive?
/
/
/
/
/
/
If died: Was listeriosis/Listeria infection on death certificate?
If died: Was listeriosis/Listeria infection on death certificate?
If died: Was listeriosis/Listeria infection on death certificate?
£ Yes
£ No
£ Unknown
£ Yes
£ No
£ Unknown
£ Yes
£ No
£ Unknown
4
CDC Listeria Initiative Case Report Form
PulseNet ID or state public health lab isolate ID ____________________________
BOX 5: (Optional): Underlying conditions and treatments (Check all that apply and specify when information available)
£ No underlying conditions, medications, or
£ Unknown
£ Pregnancy
treatments (previously healthy)
£ Other conditions
£ Immunosuppressive medication
£ Cancer/malignancy
£ Crohn’s disease
£ Corticosteroids/steroids
£ Leukemia
£ Diabetes mellitus
£ Cancer chemotherapy
£ Lymphoma
£ Type 1
£ Other immunosuppressive therapy (specify)
£ Hodgkin’s
£ Type 2
__________________________________
£ Non-Hodgkin’s
£ Giant cell (temporal) arteritis
£ Excessive alcohol use
£ Multiple myeloma
£ Hemochromatosis/iron overload
£ Injection drug use, e.g., heroin
£ Myeloproliferative disorder
£ HIV/AIDS*
£ Medications that suppress stomach acid (e.g.,
£ Other cancer/malignancy (specify)
£ HIV (no AIDS)
Maalox, Zantac, Prilosec, Nexium)
__________________________________
£ AIDS
(specify medications, if available): ____________
£ Lupus
£ On kidney dialysis
________________________________
£ Rheumatoid arthritis
£ Cirrhosis/advanced liver disease
£ Sarcoidosis
*Note that some regulations in some states do not permit
£ Chronic obstructive pulmonary disease (COPD)
£ Sickle cell disease
reporting of HIV status
£ Heart disease (specify)
£ Splenectomy/asplenia
__________________________________
£ Ulcerative colitis
£ Organ transplant (specify)
£ Other condition (specify)
__________________________________
__________________________________
Was patient or surrogate able to be interviewed? £ Yes £ No
If no, why not?
Refused
Unable to reach
Language barrier
Other (specify) ___________________________
£
£
£
£
If you are not able to interview the patient or surrogate and no food exposure information is available, please submit only pages 3–5 of this form to CDC.
(Please also include page 6 if you are able to record symptoms associated with listeriosis)
Please send completed forms to:
Enteric Diseases Epidemiology Branch, Centers for Disease Control and Prevention
Mailstop C-09
Atlanta, GA 30329.
Fax: (404) 639-2205; Email: Listeria@cdc.gov.
5