"Hospitalized and Fatal Cases of Influenza - Case Report Form" - Connecticut

Hospitalized and Fatal Cases of Influenza - Case Report Form is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

Form Details:

  • Released on November 13, 2018;
  • The latest edition currently provided by the Connecticut State Department of Public Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

ADVERTISEMENT
ADVERTISEMENT

Download "Hospitalized and Fatal Cases of Influenza - Case Report Form" - Connecticut

345 times
Rate (4.8 / 5) 24 votes
State of Connecticut
Department of Public Health
410 Capitol Ave., MS#11FDS
P.O. Box 0308
Hartford, CT 06134-0308
Phone: 860-509-7994
Fax: 860-509-7910
Hospitalized and Fatal Cases of Influenza – Case Report Form
Patient Information
Date of Birth:
Last Name:
MI:
First Name:
Street Address:
City:
State:
Zip code:
Gender:  Female  Male  Other:
If female, pregnant?  Yes  No  Unk. Due date:
 White
 Black/African Amer.
 Asian
 Native Amer./Alaska Native
Race:
 Nat. Hawaiian/Other Pacific Is.
 Other:
 Yes
 No
 Unk.
Ethnicity: Hispanic/Latino
 Yes
 No  Unknown work location:
Is the patient a Health Care Worker?
Is the patient a resident of a Longer Term Care Facility?  Yes
 No  Unknown name/location:
 Yes
 No  Unknown name location:
Is the patient a College or University student?
 Yes
 No  Unknown name location:
Is the patient a Primary or Secondary School student?
 Yes
 No  Unknown name/location:
Is the patient enrolled in a Day Care Center?
Did patient recently return from international travel?  Yes
 No  Unknown
location:
Additional Information
Microbiologic Testing
Check result for each test.
Medical record number:
Test Method
Collection Date
Pos.
Neg.
 Yes  No  Unk.
 Rapid
Was case hospitalized?
(antigen)
 IFA/DFA
Was case in an ICU/PICU? Yes  No  Unk.
 RT PCR
Hospital name:
(rapid or other)
 Viral Culture
Date of admission:
 Other:
Date of discharge:
Physician name:
Collection date:
Physician phone:
Antiviral use (check all that apply)
Influenza type/subtype:
 Oseltamivir
 Zanamivir
 Type A (H1N1) 2009
(Tamiflu®)
(Relenza®)
 Peramivir
 Baloxavir marboxil
 Type A (H3N2) Seasonal
(Rapivab®)
(Xofluza®)
 Type A Unspecified
Date treatment initiated:
 Type B Seasonal
Received current season flu vaccine:
 Yes
 No
 Unknown
 Type Unknown
 Yes
 No
 Unknown
 Other flu type:
Did case die?
 Other respiratory viruses:
Date of death:
Cause of death:
Person completing form:
Phone number:
ICP Flu Hosp. Death form rev. 11/13/2018
State of Connecticut
Department of Public Health
410 Capitol Ave., MS#11FDS
P.O. Box 0308
Hartford, CT 06134-0308
Phone: 860-509-7994
Fax: 860-509-7910
Hospitalized and Fatal Cases of Influenza – Case Report Form
Patient Information
Date of Birth:
Last Name:
MI:
First Name:
Street Address:
City:
State:
Zip code:
Gender:  Female  Male  Other:
If female, pregnant?  Yes  No  Unk. Due date:
 White
 Black/African Amer.
 Asian
 Native Amer./Alaska Native
Race:
 Nat. Hawaiian/Other Pacific Is.
 Other:
 Yes
 No
 Unk.
Ethnicity: Hispanic/Latino
 Yes
 No  Unknown work location:
Is the patient a Health Care Worker?
Is the patient a resident of a Longer Term Care Facility?  Yes
 No  Unknown name/location:
 Yes
 No  Unknown name location:
Is the patient a College or University student?
 Yes
 No  Unknown name location:
Is the patient a Primary or Secondary School student?
 Yes
 No  Unknown name/location:
Is the patient enrolled in a Day Care Center?
Did patient recently return from international travel?  Yes
 No  Unknown
location:
Additional Information
Microbiologic Testing
Check result for each test.
Medical record number:
Test Method
Collection Date
Pos.
Neg.
 Yes  No  Unk.
 Rapid
Was case hospitalized?
(antigen)
 IFA/DFA
Was case in an ICU/PICU? Yes  No  Unk.
 RT PCR
Hospital name:
(rapid or other)
 Viral Culture
Date of admission:
 Other:
Date of discharge:
Physician name:
Collection date:
Physician phone:
Antiviral use (check all that apply)
Influenza type/subtype:
 Oseltamivir
 Zanamivir
 Type A (H1N1) 2009
(Tamiflu®)
(Relenza®)
 Peramivir
 Baloxavir marboxil
 Type A (H3N2) Seasonal
(Rapivab®)
(Xofluza®)
 Type A Unspecified
Date treatment initiated:
 Type B Seasonal
Received current season flu vaccine:
 Yes
 No
 Unknown
 Type Unknown
 Yes
 No
 Unknown
 Other flu type:
Did case die?
 Other respiratory viruses:
Date of death:
Cause of death:
Person completing form:
Phone number:
ICP Flu Hosp. Death form rev. 11/13/2018