Form CDC52.56 "Legionellosis Case Report"

What Is Form CDC52.56?

This is a legal form that was released by the U.S. Department of Health and Human Services - Centers for Disease Control and Prevention on January 1, 2020 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

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  • Released on January 1, 2020;
  • The latest available edition released by the U.S. Department of Health and Human Services - Centers for Disease Control and Prevention;
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Reset Patient ID Info
Patient’s Name: ____________________________________________________ Telephone Number: ________________ Hospital: ___________________
LAST / FIRST / MI
Address: _________________________________________________________________
___________________Patient Chart No.: __________________
NUMBER / STREET / APT NO / CITY / STATE
ZIP CODE
PATIENT IDENTIFIER INFORMATION IS NOT TRANSMITTED TO CDC
Form Approved OMB No. 0920-0728
CDC • National Center for Immunization and Respiratory Diseases
LEGIONELLOSIS CASE REPORT
Reset Form
(DISEASE CAUSED BY ANY LEGIONELLA SPECIES)
Department of Health & Human Services
☐☐☐☐☐☐
Case No.:
Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, 30329
http://www.cdc.gov/legionella/index.htm
(CDC use only)
PATIENT INfORmATION
1. State Health Dept. Case No.: 2. Reporting State:
3. County of Residence:
5. Occupation:
4. State of Residence:
☐☐
☐☐
8. Ethnicity:
9. Race:
7. Sex:
6a. Date of Birth:
6b. Age:
(check all that apply)
1
Black or African American
1
Days
American Indian/
☐☐ ☐☐ ☐☐☐☐ ☐☐☐
Native Hawaiian or
1
1
Male
1
Hispanic/Latino
9
Unknown
1
2
Mos.
Alaska Native
Other Pacific Islander
Mo.
Day
Year
3
Years
2
Not Hispanic/Latino
1
Asian
2
Female
1
White
1
Unknown
CLINICAL ILLNESS
10. Diagnosis:
11. Date of symptom
12. Date of first report to
(check one)
onset of legionellosis:
public health at any level:
1
Legionnaires’ Disease (pneumonia, clinical or X-ray diagnosed)
☐☐ ☐☐ ☐☐☐☐
☐☐ ☐☐ ☐☐☐☐
2
Pontiac Fever (fever and myalgia without pneumonia)
Mo.
Day
Year
Mo.
Day
Year
8
Extrapulmonary Legionellosis: _____________________
13. Was the patient hospitalized during treatment for legionellosis?
14. Outcome of illness:
1
Yes 2
No 9
Unknown
3
Still ill
1
Survived
☐☐ ☐☐ ☐☐☐☐
Hospital name:
____________________________________________
If yes, date of admission:
9
Unknown
2
Died
Mo.
Day
Year
City, State: _______________________________________________
ExPOSuRE INfORmATION
15. In the 14 days before onset, did the patient spend any nights away from home (excluding healthcare settings)?
1
Yes* 2
No 9
Unknown
If yes, please complete the following table.
(check one)
room
ARRIVAL DATE
DEPARTURE
AccommodAtion nAme
Address
city
stAte
Zip
country
number
OF STAY
DATE OF STAY
*If yes, was this case reported to CDC at travellegionella@cdc.gov?
1
Yes 2
No 9
Unknown
16. In the 14 days before onset, did the patient get in or spend time near a whirlpool spa (i.e., hot tub)?
1
Yes 2
No 9
Unknown If yes, describe where: _________________________ If yes, list dates: ________________________
(check one)
17. In the 14 days before onset, did the patient use a nebulizer, CPAP, BiPAP or any other respiratory therapy equipment for the treatment of sleep
apnea, COPD, asthma or for any other reason?
1
Yes 2
No 9
Unknown If yes, does this device use a humidifier? 1
Yes 2
No 9
Unknown
(check one)
If yes, what type of water is used in the device? (check all that apply) 1
Sterile 1
Distilled 1
Bottled 1
Tap 1
Other 1
Unknown
18. In the 14 days before onset, did the patient visit or stay in a healthcare setting (e.g., hospital, long term care/rehab/skilled nursing facility, clinic)?
1
Yes 2
No 9
Unknown If yes, please complete the following table.
(check one)
is tHis
START DATE
type of HeAltHcAre
end dAte
type of exposure
nAme of
fAcility Also
setting / fAcility
OF VISIT/
OF VISIT/
reAson for visit
city
stAte
fAcility
A trAnsplAnt
(cHeck one)
ADMISSION
ADMISSION
(cHeck one)
center?
1
Hospital
1
Inpatient
1
Yes
2
Long term care
2
Outpatient
2
No
3
Clinic
3
Visitor or volunteer
9
Unknown
8
Other: ______________
4
Employee
1
Hospital
1
Inpatient
1
Yes
2
Long term care
2
Outpatient
2
No
3
Clinic
3
Visitor or volunteer
9
Unknown
8
Other: ______________
4
Employee
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 estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Project Clearance Officer, 1600
Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0728). Do not send the completed form to this address. While your response is voluntary your cooperation is necessary for the understanding and control
of this disease.
CDC 52.56 Rev. 11/2013
Legionellosis Case Report
Page 1 of 2
CDC 52.56 (E), January 2020, CDC Adobe Acrobat 10.1, S508 Electronic Version, January 2020
CS310434
– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –
Save Form
Next Page
Reset Patient ID Info
Patient’s Name: ____________________________________________________ Telephone Number: ________________ Hospital: ___________________
LAST / FIRST / MI
Address: _________________________________________________________________
___________________Patient Chart No.: __________________
NUMBER / STREET / APT NO / CITY / STATE
ZIP CODE
PATIENT IDENTIFIER INFORMATION IS NOT TRANSMITTED TO CDC
Form Approved OMB No. 0920-0728
CDC • National Center for Immunization and Respiratory Diseases
LEGIONELLOSIS CASE REPORT
Reset Form
(DISEASE CAUSED BY ANY LEGIONELLA SPECIES)
Department of Health & Human Services
☐☐☐☐☐☐
Case No.:
Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, 30329
http://www.cdc.gov/legionella/index.htm
(CDC use only)
PATIENT INfORmATION
1. State Health Dept. Case No.: 2. Reporting State:
3. County of Residence:
5. Occupation:
4. State of Residence:
☐☐
☐☐
8. Ethnicity:
9. Race:
7. Sex:
6a. Date of Birth:
6b. Age:
(check all that apply)
1
Black or African American
1
Days
American Indian/
☐☐ ☐☐ ☐☐☐☐ ☐☐☐
Native Hawaiian or
1
1
Male
1
Hispanic/Latino
9
Unknown
1
2
Mos.
Alaska Native
Other Pacific Islander
Mo.
Day
Year
3
Years
2
Not Hispanic/Latino
1
Asian
2
Female
1
White
1
Unknown
CLINICAL ILLNESS
10. Diagnosis:
11. Date of symptom
12. Date of first report to
(check one)
onset of legionellosis:
public health at any level:
1
Legionnaires’ Disease (pneumonia, clinical or X-ray diagnosed)
☐☐ ☐☐ ☐☐☐☐
☐☐ ☐☐ ☐☐☐☐
2
Pontiac Fever (fever and myalgia without pneumonia)
Mo.
Day
Year
Mo.
Day
Year
8
Extrapulmonary Legionellosis: _____________________
13. Was the patient hospitalized during treatment for legionellosis?
14. Outcome of illness:
1
Yes 2
No 9
Unknown
3
Still ill
1
Survived
☐☐ ☐☐ ☐☐☐☐
Hospital name:
____________________________________________
If yes, date of admission:
9
Unknown
2
Died
Mo.
Day
Year
City, State: _______________________________________________
ExPOSuRE INfORmATION
15. In the 14 days before onset, did the patient spend any nights away from home (excluding healthcare settings)?
1
Yes* 2
No 9
Unknown
If yes, please complete the following table.
(check one)
room
ARRIVAL DATE
DEPARTURE
AccommodAtion nAme
Address
city
stAte
Zip
country
number
OF STAY
DATE OF STAY
*If yes, was this case reported to CDC at travellegionella@cdc.gov?
1
Yes 2
No 9
Unknown
16. In the 14 days before onset, did the patient get in or spend time near a whirlpool spa (i.e., hot tub)?
1
Yes 2
No 9
Unknown If yes, describe where: _________________________ If yes, list dates: ________________________
(check one)
17. In the 14 days before onset, did the patient use a nebulizer, CPAP, BiPAP or any other respiratory therapy equipment for the treatment of sleep
apnea, COPD, asthma or for any other reason?
1
Yes 2
No 9
Unknown If yes, does this device use a humidifier? 1
Yes 2
No 9
Unknown
(check one)
If yes, what type of water is used in the device? (check all that apply) 1
Sterile 1
Distilled 1
Bottled 1
Tap 1
Other 1
Unknown
18. In the 14 days before onset, did the patient visit or stay in a healthcare setting (e.g., hospital, long term care/rehab/skilled nursing facility, clinic)?
1
Yes 2
No 9
Unknown If yes, please complete the following table.
(check one)
is tHis
START DATE
type of HeAltHcAre
end dAte
type of exposure
nAme of
fAcility Also
setting / fAcility
OF VISIT/
OF VISIT/
reAson for visit
city
stAte
fAcility
A trAnsplAnt
(cHeck one)
ADMISSION
ADMISSION
(cHeck one)
center?
1
Hospital
1
Inpatient
1
Yes
2
Long term care
2
Outpatient
2
No
3
Clinic
3
Visitor or volunteer
9
Unknown
8
Other: ______________
4
Employee
1
Hospital
1
Inpatient
1
Yes
2
Long term care
2
Outpatient
2
No
3
Clinic
3
Visitor or volunteer
9
Unknown
8
Other: ______________
4
Employee
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 estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Project Clearance Officer, 1600
Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0728). Do not send the completed form to this address. While your response is voluntary your cooperation is necessary for the understanding and control
of this disease.
CDC 52.56 Rev. 11/2013
Legionellosis Case Report
Page 1 of 2
CDC 52.56 (E), January 2020, CDC Adobe Acrobat 10.1, S508 Electronic Version, January 2020
CS310434
– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –
Save Form
Next Page
Previous Page
State Health Dept. Case No.:
__________________________________
19. Was this case associated with a healthcare exposure:
(check one)
Presumptively: Patient had 10 or more days of continuous stay at a
Possibly: Patient had exposure to a healthcare facility for a portion
1
3
healthcare facility during the 14 days before onset of symptoms.
of the 14 days prior to onset
No: No exposure to a healthcare facility in the 14 days prior to onset
2
Other (specify) ______________________________________
Unknown
8
9
20. In the 14 days before onset, did the patient visit or stay in an assisted living facility or senior living facility?
1 □ Yes 2 □ No 9 □ Unknown
(check one)
START DATE
END DATE
type of fAcility
type of exposure
nAme of fAcility
city
stAte
OF VISIT
OF VISIT
1
Assisted Living
1
Resident
2
Visitor or Volunteer
3
Employee
2
Senior Living
1
Resident
(Includes retirement
2
Visitor or Volunteer
homes without skilled
3
Employee
nursing or personal care)
21. Was this case associated with a known outbreak or possible cluster?
1 □ Yes 2 □ No 9 □ Unknown
(check one)
If yes, specify name of facility, city, and state of outbreak: __________________________________________________________________________
LAbORATORy DATA
PLEASE CHECK ALL METHODS OF DIAGNOSIS WHICH APPLY:
1
CONfIRmED CASE
2
SuSPECT CASE
Urinary Antigen Positive: If yes,
5
Fourfold rise in antibody titer OTHER THAN Legionella
1
pneumophila serogroup 1 or to multiple species or
☐☐ ☐☐ ☐☐☐☐
Date Collected:
serogroups of Legionella using pooled antigen: If yes,
Mo.
Day
Year
☐☐ ☐☐ ☐☐☐☐
Initial (acute) titer: ____________ Date Collected:
Mo.
Day
Year
☐☐ ☐☐ ☐☐☐☐
2
Culture Positive: If yes,
Convalescent titer: ___________ Date Collected:
Mo.
Day
Year
☐☐ ☐☐ ☐☐☐☐
Date Collected:
Species: ______________________________________ Serogroup: _____________________
Mo.
Day
Year
6
Direct Fluorescent Antibody (DFA) or
Site: 1
lung biopsy
2
respiratory secretions (e.g., sputum, BAL)
3
pleural fluid
Immunohistochemistry (IHC) Positive: If yes,
4
blood
8
other (specify) _______________________________________
☐☐ ☐☐ ☐☐☐☐
Date Collected:
Species: ______________________________________ Serogroup: ____________________
Mo.
Day
Year
Site: 1
lung biopsy
2
respiratory secretions (e.g., sputum, BAL)
3
pleural fluid
4
blood
8
other (specify) _______________________________________
Fourfold rise in antibody titer to
3
Species: ______________________________________ Serogroup: _____________________
Legionella pneumophila serogroup 1: If yes,
4
Nucleic Acid Assay (e.g., PCR): If yes,
☐☐ ☐☐ ☐☐☐☐
Initial (acute) titer: ____________ Date Collected:
☐☐ ☐☐ ☐☐☐☐
Mo.
Day
Year
Date Collected:
Mo.
Day
Year
☐☐ ☐☐ ☐☐☐☐
Convalescent titer: ___________ Date Collected:
Site: 1
lung biopsy
2
respiratory secretions (e.g., sputum, BAL)
3
pleural fluid
Mo.
Day
Year
4
blood
8
other (specify) _______________________________________
Species: ______________________________________ Serogroup: _____________________
Indicate epidemiologic link in the notes field below
3
PROBABLE CASE
REPORTING INSTRuCTIONS
INTERvIEwER IDENTIfICATION
Local Health Dept. Please submit this document to:
Interviewer’s Name:
State Health Dept. Official who reviewed this report:
State/DHD/SSS via your CD clerk
State Health Dept. Return completed form to:
Affiliation:
Title:
Respiratory Diseases Branch, Mailstop H24-6
Office of Infectious Diseases
Telephone No.:
Telephone No.:
Centers for Disease Control and Prevention
1600 Clifton Rd. NE, Atlanta, GA 30329
COmmENTS
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
CDC 52.56 Rev. 11/2013
Legionellosis Case Report
Page 2 of 2
CDC 52.56 (E), January 2020, CDC Adobe Acrobat 10.1, S508 Electronic Version, January 2020
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