Form CS313648 "Tickborne Rickettsial Disease Case Report"

What Is Form CS313648?

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 December 1, 2020 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 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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  • Fill out the form in our online filing application.

Download a fillable version of Form CS313648 by clicking the link below or browse more documents and templates provided by the U.S. Department of Health and Human Services - Centers for Disease Control and Prevention.

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Tickborne Rickettsial Disease Case Report
CDC#
Use for Spotted Fever Rickettsiosis (SFR) including Rocky Mountain spotted fever (RMSF),
Anaplasma phagocytophilum infection, Ehrlichia chaffeensis infection, Ehrlichia ewingii infection,
and Undetermined human ehrlichiosis/anaplasmosis. Visit
https://wwwn.cdc.gov/nndss/case-definitions.html
for complete case definitions or visit the disease website(s) for a fillable/downloadable PDF version of this case report form.
Date submitted (mm/dd/yyyy):
Patient Name:
Healthcare provider's name:
Address:
Local Patient ID.: (if reported)
City:
Local ID
Site
State
1. State of residence (postal abbrev.):
3. Sex:
2. County of residence:
1
Male
2
Female
9
Unknown
6. Hispanic or Latino ethnicity:
4. Patient age (years)
5. Race (check all that apply):
at time of case
7
Unknown
4
Asian
1
Yes
1
White
investigation:
8
Refused
5
Native Hawaiian or Other Pacific Islander
2
No
2
Black or African American
6
Other race
9
Unknown
3
American Indian or Alaska Native
7. In the two weeks before symptom onset or diagnosis (use earlier date), did the patient travel out of their county, state, or country of residence?
1
Yes
2
No 9
Unknown
When did they arrive?
When did they depart?
Destination
(county, state, or country):
(mm/dd/yyyy)
(mm/dd/yyyy)
8. In the two weeks before symptom onset or diagnosis
If yes, date
If the patient removed a tick from their body, what was the geographic
(use earlier date), did the patient notice any tick bites?
(mm/dd/yyyy):
location at the time (county, state, or country)?
1
Yes
2
No 9
Unknown
10. Date of illness onset
9. Clinical evidence of tickborne rickettsial disease:
(mm/dd/yyyy):
Fever
1
Yes
2
No
9
Unknown
Thrombocytopenia
1
Yes
2
No
9
Unknown
Rash
1
Yes
2
No
9
Unknown
Hepatic transaminase elevation
1
Yes
2
No
9
Unknown
Eschar
1
Yes
2
No
9
Unknown
Leukopenia
1
Yes
2
No
9
Unknown
Headache 1
Yes
2
No
9
Unknown
Other, specify:
1
Yes
2
No
9
Unknown
Myalgia
1
Yes
2
No
9
Unknown
Anemia
1
Yes
2
No
9
Unknown
12. At the time of diagnosis, was the patient immunocompromised due
11. Did the patient experience any severe complications in the clinical course of this illness?
to medical condition(s) or treatment(s)
(such as one of the following:
1
Yes 2
No
9
Unknown
chemotherapy for current illness, HIV, anti-rejection drugs post-transplant,
corticosteroids >14 days [such as prednisone, methylprednisolone, or
If the patient experienced severe complications due to this illness, specify the complication(s):
?
dexamethasone], rheumatoid arthritis [with use of immunomodulator])
1
Acute respiratory distress syndrome (ARDS)
2
Disseminated intravascular coagulation (DIC)
1
Yes
2
No
9
Unknown
3
Meningitis/encephalitis
Specify condition(s) or treatment(s):
4
Organ failure
5
Other, specify:
If yes, date
13. Was the patient hospitalized because of this illness?
Admission date
Discharge date
14. Did the patient die from this illness or
(mm/dd/yyyy):
(mm/dd/yyyy):
(mm/dd/yyyy):
complications of this illness?
1
Yes
2
No 9
Unknown
1
Yes
2
No
9
Unknown
15. Were antibiotics prescribed
Specify antibiotic (if multiple antibiotics were
Date treatment was prescribed
Prescribed duration
for this infection
prescribed, please specify in comments):
(mm/dd/yyyy):
(days):
1
Yes 2
No 9
Unknown
16. In the year before symptom onset or diagnosis
16b.Was the patient's infection transfusion-associated?
16a. Date of blood transfusion (mm/dd/yyyy):
(use earlier date), did the patient receive a
blood transfusion?
1
Yes
2
No
9
Unknown
16c. If a blood product was implicated in the infection,
1
Yes 2
No 9
Unknown
specify which type(s):
If no or unknown, skip to Q. 17 below.
1
Plasma product
2
Platelet product
3
Red blood cells
Otherwise, continue with 16a, 16b, and 16c.
4
Unknown
5
Other, specify:
17. |n the year before symptom onset or diagnosis
17a. Date of transplant (mm/dd/yyyy):
17b. Was the patient's infection transplant-associated?
(use earlier date), did the patient receive an
organ transplant?
1
Yes
2
No
9
Unknown
1
Yes
2
No 9
Unknown
17c. If the patient received an organ transplant, specify which organ(s):
If no or unknown, skip to Q. 18 below.
Otherwise, continue with 17a, 17b, and 17c.
CS313648 Dec 2020
Tickborne Rickettsial Disease Case Report
CDC#
Use for Spotted Fever Rickettsiosis (SFR) including Rocky Mountain spotted fever (RMSF),
Anaplasma phagocytophilum infection, Ehrlichia chaffeensis infection, Ehrlichia ewingii infection,
and Undetermined human ehrlichiosis/anaplasmosis. Visit
https://wwwn.cdc.gov/nndss/case-definitions.html
for complete case definitions or visit the disease website(s) for a fillable/downloadable PDF version of this case report form.
Date submitted (mm/dd/yyyy):
Patient Name:
Healthcare provider's name:
Address:
Local Patient ID.: (if reported)
City:
Local ID
Site
State
1. State of residence (postal abbrev.):
3. Sex:
2. County of residence:
1
Male
2
Female
9
Unknown
6. Hispanic or Latino ethnicity:
4. Patient age (years)
5. Race (check all that apply):
at time of case
7
Unknown
4
Asian
1
Yes
1
White
investigation:
8
Refused
5
Native Hawaiian or Other Pacific Islander
2
No
2
Black or African American
6
Other race
9
Unknown
3
American Indian or Alaska Native
7. In the two weeks before symptom onset or diagnosis (use earlier date), did the patient travel out of their county, state, or country of residence?
1
Yes
2
No 9
Unknown
When did they arrive?
When did they depart?
Destination
(county, state, or country):
(mm/dd/yyyy)
(mm/dd/yyyy)
8. In the two weeks before symptom onset or diagnosis
If yes, date
If the patient removed a tick from their body, what was the geographic
(use earlier date), did the patient notice any tick bites?
(mm/dd/yyyy):
location at the time (county, state, or country)?
1
Yes
2
No 9
Unknown
10. Date of illness onset
9. Clinical evidence of tickborne rickettsial disease:
(mm/dd/yyyy):
Fever
1
Yes
2
No
9
Unknown
Thrombocytopenia
1
Yes
2
No
9
Unknown
Rash
1
Yes
2
No
9
Unknown
Hepatic transaminase elevation
1
Yes
2
No
9
Unknown
Eschar
1
Yes
2
No
9
Unknown
Leukopenia
1
Yes
2
No
9
Unknown
Headache 1
Yes
2
No
9
Unknown
Other, specify:
1
Yes
2
No
9
Unknown
Myalgia
1
Yes
2
No
9
Unknown
Anemia
1
Yes
2
No
9
Unknown
12. At the time of diagnosis, was the patient immunocompromised due
11. Did the patient experience any severe complications in the clinical course of this illness?
to medical condition(s) or treatment(s)
(such as one of the following:
1
Yes 2
No
9
Unknown
chemotherapy for current illness, HIV, anti-rejection drugs post-transplant,
corticosteroids >14 days [such as prednisone, methylprednisolone, or
If the patient experienced severe complications due to this illness, specify the complication(s):
?
dexamethasone], rheumatoid arthritis [with use of immunomodulator])
1
Acute respiratory distress syndrome (ARDS)
2
Disseminated intravascular coagulation (DIC)
1
Yes
2
No
9
Unknown
3
Meningitis/encephalitis
Specify condition(s) or treatment(s):
4
Organ failure
5
Other, specify:
If yes, date
13. Was the patient hospitalized because of this illness?
Admission date
Discharge date
14. Did the patient die from this illness or
(mm/dd/yyyy):
(mm/dd/yyyy):
(mm/dd/yyyy):
complications of this illness?
1
Yes
2
No 9
Unknown
1
Yes
2
No
9
Unknown
15. Were antibiotics prescribed
Specify antibiotic (if multiple antibiotics were
Date treatment was prescribed
Prescribed duration
for this infection
prescribed, please specify in comments):
(mm/dd/yyyy):
(days):
1
Yes 2
No 9
Unknown
16. In the year before symptom onset or diagnosis
16b.Was the patient's infection transfusion-associated?
16a. Date of blood transfusion (mm/dd/yyyy):
(use earlier date), did the patient receive a
blood transfusion?
1
Yes
2
No
9
Unknown
16c. If a blood product was implicated in the infection,
1
Yes 2
No 9
Unknown
specify which type(s):
If no or unknown, skip to Q. 17 below.
1
Plasma product
2
Platelet product
3
Red blood cells
Otherwise, continue with 16a, 16b, and 16c.
4
Unknown
5
Other, specify:
17. |n the year before symptom onset or diagnosis
17a. Date of transplant (mm/dd/yyyy):
17b. Was the patient's infection transplant-associated?
(use earlier date), did the patient receive an
organ transplant?
1
Yes
2
No
9
Unknown
1
Yes
2
No 9
Unknown
17c. If the patient received an organ transplant, specify which organ(s):
If no or unknown, skip to Q. 18 below.
Otherwise, continue with 17a, 17b, and 17c.
CS313648 Dec 2020
18. Did the patient donate blood in the 30 days
18a. Date of blood donation
18b. Was the patient a blood donor identified during an investigation into a
prior to symptom onset?
(mm/dd/yyyy):
transfusion-associated infection?
1
Yes
2
No
9
Unknown
1
Yes
2
No
9
Unknown
If no or unknown, skip to Q. 19 below.
18d. Was the blood bank/hospital/
18c. If a blood product was implicated in the infection, specify which type(s):
Otherwise, continue with 18a, 18b, 18c, and 18d.
transplant service notified?
1
Plasma product
2
Platelet product
3
Red blood cells
4
Unknown
5
Other (please specify in comments)
1
Yes
2
No
9
Unknown
19. Performing laboratory name (organization that performed diagnostic testing):
State (postal abbrev.):
20. Serology 1 collection date (mm/dd/yyyy):
Serology 2 collection date* (mm/dd/yyyy):
Serologic Tests
Titer
Results
Serologic Tests
Titer
Results
IFA - IgG
IFA - IgG
Positive
Negative
Not performed
Positive
Negative
Not performed
IFA - IgM
Positive
Negative
Not performed
IFA - IgM
Positive
Negative
Not performed
Other, specify:
Other, specify:
Positive
Negative
Not performed
Positive
Negative
Not performed
If additional serology testing performed, please specify in comments.
*Was there a fourfold change in antibody titer between the two IgG serum specimens?
Yes
No
21. Other Diagnostic Tests:
Date Collected
Tests
Specimen Type
Results
(mm/dd/yyyy)
PCR
Positive
Negative
Not performed
Morulae visualization
Positive
Negative
Not performed
Immunostain
Positive
Negative
Not performed
Culture (confirmed by PCR)
Positive
Negative
Not performed
22. If PCR, immunostain, or sequencing performed, specify genus or species identified:
1
Anaplasma phagocytophilum
6
Genera Ehrlichia/Anaplasma
10
Rickettsia species 364D
2
Ehrlichia chaffeensis
7
Rickettsia africae
11
Rickettsia species (pan-Rickettsia)
3
Ehrlichia ewingii
8
Rickettsia parkeri
12
Spotted fever group Rickettsiae
4
Ehrlichia muris eauclairensis
9
Rickettsia rickettsii
13
Other, specify:
5
Ehrlichia species (pan-Ehrlichia)
23. Condition or event that constitutes the reason the notification is being sent:
24. Case Outcome
:
(only confirmed and probable cases to be reported to CDC)
1
SFR (including RMSF)
4
Ehrlichiosis - E.ewingii
1
Confirmed
3
Suspect
9
Unknown
2
Ehrlichiosis - E. chaffeensis
5
Undetermined human ehrlichiosis/anaplasmosis
2
Probable
4
Not a Case
3
Anaplasmosis - A. phagocytophilum
State Health Department Official who reviewed this report:
Name:
Phone number:
Title:
Email address:
Date:
Comments:
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