Form CDPH8687 A "West Nile Virus (Wnv) Infection Case Report Supplemental Investigation Form" - California

What Is Form CDPH8687 A?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2015;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CDPH8687 A by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH8687 A "West Nile Virus (Wnv) Infection Case Report Supplemental Investigation Form" - California

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State of California-Health and Human Services Agency
California Department of Public Health
Viral and Rickettsial Disease Laboratory
850 Marina Bay Parkway
Richmond, CA 94804
West Nile Virus (WNV) Infection Case Report
SUPPLEMENTAL INVESTIGATION FORM
Date Form Completed:___/___/____
Beginning in 2014, the Centers for Disease Control and Prevention (CDC) will collect surveillance data on patients with laboratory-confirmed
WNV infection who lack a subjective or measured fever. Initial reports of WNV infections should be sent to the California Department of Public
Health immediately after they have been confirmed. However, this supplemental investigation form is not time-sensitive and can be submitted at
any time after a case has been reported.
Clinical signs and symptoms of patients with laboratory evidence of West Nile virus infection with no
reported fever:
Patient Name (Last, First): ______________________________________________ DOB:___/___/___
1.
Fever
Yes
No
Unknown
2.
Chills or rigors
Yes
No
Unknown
3.
Rash
Yes
No
Unknown
4.
Headache
Yes
No
Unknown
5.
Fatigue or malaise
Yes
No
Unknown
6.
Conjunctitivis
Yes
No
Unknown
7.
Nausea or vomiting
Yes
No
Unknown
8.
Diarrhea
Yes
No
Unknown
9.
Myalgia
Yes
No
Unknown
10. Arthralgia
Yes
No
Unknown
11. Arthritis
Yes
No
Unknown
12. Paresis or paralysis
Yes
No
Unknown
13. Stiff neck
Yes
No
Unknown
14. Ataxia
Yes
No
Unknown
15. Altered mental status
Yes
No
Unknown
16. Parkinsonism or cogwheel rigidity
Yes
No
Unknown
17. Seizures
Yes
No
Unknown
18. Retro-orbital Pain
Yes
No
Unknown
19. Tourniquet Test Positive
Yes
No
Unknown
3
20. Leukopenia (<5,000/mm
)
Yes
No
Unknown
21. Abdominal Pain Tenderness
Yes
No
Unknown
22. Persisting Vomiting (>=3 times over 24 hrs)
Yes
No
Unknown
23. Extravascular Fluid Accumulation
Yes
No
Unknown
24. Mucosal Bleeding
Yes
No
Unknown
25. Liver Enlargement (>2 cm)
Yes
No
Unknown
26. Increasing Hematocrit with Decreased Platelet Count
Yes
No
Unknown
a
27. Severe Plasma Leakage
Yes
No
Unknown
b
28. Severe Bleeding
Yes
No
Unknown
c
29. Severe Organ Involvement
Yes
No
Unknown
a
As evidenced by hypovolemic shock and/or extravascular fluid accumulation (e.g., pleural or pericardial effusion, ascites) with respiratory distress. A high
hematocrit value for patient age and sex offers further evidence of plasma leakage
b
Such as from the gastrointestinal tract (e.g., hematemesis, melena) or vagina (menorrhagia) and requiring medical intervention including intravenous fluid
resuscitation or blood transfusion.
c
Could include any of the following: Elevated liver transaminases: aspartate aminotransferase (AST) or alanine aminotransferase (ALT) C1,000 per liter (U/L);
Impaired level of consciousness and/or diagnosis of encephalitis, encephalopathy, or meningitis; Heart or other organ involvement including myocarditis,
cholecystitis, and pancreatitis.
Please include this form in the patient’s CalREDIE electronic filing cabinet or fax to (510) 307-8599
CDPH 8687 A (5/15)
Page 1 of 1
State of California-Health and Human Services Agency
California Department of Public Health
Viral and Rickettsial Disease Laboratory
850 Marina Bay Parkway
Richmond, CA 94804
West Nile Virus (WNV) Infection Case Report
SUPPLEMENTAL INVESTIGATION FORM
Date Form Completed:___/___/____
Beginning in 2014, the Centers for Disease Control and Prevention (CDC) will collect surveillance data on patients with laboratory-confirmed
WNV infection who lack a subjective or measured fever. Initial reports of WNV infections should be sent to the California Department of Public
Health immediately after they have been confirmed. However, this supplemental investigation form is not time-sensitive and can be submitted at
any time after a case has been reported.
Clinical signs and symptoms of patients with laboratory evidence of West Nile virus infection with no
reported fever:
Patient Name (Last, First): ______________________________________________ DOB:___/___/___
1.
Fever
Yes
No
Unknown
2.
Chills or rigors
Yes
No
Unknown
3.
Rash
Yes
No
Unknown
4.
Headache
Yes
No
Unknown
5.
Fatigue or malaise
Yes
No
Unknown
6.
Conjunctitivis
Yes
No
Unknown
7.
Nausea or vomiting
Yes
No
Unknown
8.
Diarrhea
Yes
No
Unknown
9.
Myalgia
Yes
No
Unknown
10. Arthralgia
Yes
No
Unknown
11. Arthritis
Yes
No
Unknown
12. Paresis or paralysis
Yes
No
Unknown
13. Stiff neck
Yes
No
Unknown
14. Ataxia
Yes
No
Unknown
15. Altered mental status
Yes
No
Unknown
16. Parkinsonism or cogwheel rigidity
Yes
No
Unknown
17. Seizures
Yes
No
Unknown
18. Retro-orbital Pain
Yes
No
Unknown
19. Tourniquet Test Positive
Yes
No
Unknown
3
20. Leukopenia (<5,000/mm
)
Yes
No
Unknown
21. Abdominal Pain Tenderness
Yes
No
Unknown
22. Persisting Vomiting (>=3 times over 24 hrs)
Yes
No
Unknown
23. Extravascular Fluid Accumulation
Yes
No
Unknown
24. Mucosal Bleeding
Yes
No
Unknown
25. Liver Enlargement (>2 cm)
Yes
No
Unknown
26. Increasing Hematocrit with Decreased Platelet Count
Yes
No
Unknown
a
27. Severe Plasma Leakage
Yes
No
Unknown
b
28. Severe Bleeding
Yes
No
Unknown
c
29. Severe Organ Involvement
Yes
No
Unknown
a
As evidenced by hypovolemic shock and/or extravascular fluid accumulation (e.g., pleural or pericardial effusion, ascites) with respiratory distress. A high
hematocrit value for patient age and sex offers further evidence of plasma leakage
b
Such as from the gastrointestinal tract (e.g., hematemesis, melena) or vagina (menorrhagia) and requiring medical intervention including intravenous fluid
resuscitation or blood transfusion.
c
Could include any of the following: Elevated liver transaminases: aspartate aminotransferase (AST) or alanine aminotransferase (ALT) C1,000 per liter (U/L);
Impaired level of consciousness and/or diagnosis of encephalitis, encephalopathy, or meningitis; Heart or other organ involvement including myocarditis,
cholecystitis, and pancreatitis.
Please include this form in the patient’s CalREDIE electronic filing cabinet or fax to (510) 307-8599
CDPH 8687 A (5/15)
Page 1 of 1