"Swine Influenza Healthcare Worker Case Report Addendum Form"

Swine Influenza Healthcare Worker Case Report Addendum Form is a 2-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.

Form Details:

  • The latest edition currently provided by the U.S. Department of Health and Human Services - Centers for Disease Control and Prevention;
  • 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 printable version of the form by clicking the link below or browse more legal forms and templates provided by the issuing department.

ADVERTISEMENT
ADVERTISEMENT

Download "Swine Influenza Healthcare Worker Case Report Addendum Form"

1140 times
Rate (4.3 / 5) 57 votes
Swine Influenza Healthcare Worker Case Report Addendum (version 3)
Please complete the standard CDC case report form in addition to this form.
(FAX to: 404-248-4094 or email to
)
casereportforms@cdc.gov
State EPI ID # (epidemiology ID) ________________
CDC EPI ID # ______________________
State lab specimen ID #1 _______________________
CDC lab specimen ID #1 ______________
State lab specimen ID #2 _________________
CDC lab specimen ID #2 ______________
CDC (lab) unique ID # ______________
Name and email of person completing this form: _____________________________________________________
Date form completed: _______________________
Occupational Information
Which title best describes your job at the healthcare facility in which you work?
___ Physician, indicate specialty: _____________________________
___ Physician assistant
___ Nurse practitioner
___ Registered nurse
___ Licensed practical nurse
___ Nursing assistant
___ Radiology technician
___ Respiratory therapist
___ Speech therapist
___ Occupational therapist
___ Physical therapist
___ Ward clerk
___ Housekeeping
Maintenance
___ Laboratory worker
___ Food services worker
___ Student, specify type: _________________________________
___ Other, specify___________________________________
Do you regularly perform direct patient care, for example, face to face contact with patients for the purpose
of diagnosis, treatment and monitoring?
___Yes ___No
Have you been fit-tested for an N-95 respirator (i.e., Tb mask)? ___ Yes ___ No ___ Don’t know
a. When were you last fit-tested? ___ <1 year ____>=1 year
b. Do you know what size you are supposed to be wearing? ___ Yes ___ No ___ Don’t know
c. Do you know where to get your size of N95 mask? ___ Yes ___ No
In the seven days prior to becoming ill with swine flu, what type of healthcare facility did you work in? (check all that
apply)
___ Acute inpatient care facility
___ Outpatient clinic, please specify type: ________________
___ Long term care facility: specify type: ________________
___ Emergency room
___ Long term acute care/assisted living facility
___ Hemodialysis Center
____Inpatient psychiatric facility
____Other, please specify ________________
___ None (e.g.., did not work)
1
Swine Influenza Healthcare Worker Case Report Addendum (version 3)
Please complete the standard CDC case report form in addition to this form.
(FAX to: 404-248-4094 or email to
)
casereportforms@cdc.gov
State EPI ID # (epidemiology ID) ________________
CDC EPI ID # ______________________
State lab specimen ID #1 _______________________
CDC lab specimen ID #1 ______________
State lab specimen ID #2 _________________
CDC lab specimen ID #2 ______________
CDC (lab) unique ID # ______________
Name and email of person completing this form: _____________________________________________________
Date form completed: _______________________
Occupational Information
Which title best describes your job at the healthcare facility in which you work?
___ Physician, indicate specialty: _____________________________
___ Physician assistant
___ Nurse practitioner
___ Registered nurse
___ Licensed practical nurse
___ Nursing assistant
___ Radiology technician
___ Respiratory therapist
___ Speech therapist
___ Occupational therapist
___ Physical therapist
___ Ward clerk
___ Housekeeping
Maintenance
___ Laboratory worker
___ Food services worker
___ Student, specify type: _________________________________
___ Other, specify___________________________________
Do you regularly perform direct patient care, for example, face to face contact with patients for the purpose
of diagnosis, treatment and monitoring?
___Yes ___No
Have you been fit-tested for an N-95 respirator (i.e., Tb mask)? ___ Yes ___ No ___ Don’t know
a. When were you last fit-tested? ___ <1 year ____>=1 year
b. Do you know what size you are supposed to be wearing? ___ Yes ___ No ___ Don’t know
c. Do you know where to get your size of N95 mask? ___ Yes ___ No
In the seven days prior to becoming ill with swine flu, what type of healthcare facility did you work in? (check all that
apply)
___ Acute inpatient care facility
___ Outpatient clinic, please specify type: ________________
___ Long term care facility: specify type: ________________
___ Emergency room
___ Long term acute care/assisted living facility
___ Hemodialysis Center
____Inpatient psychiatric facility
____Other, please specify ________________
___ None (e.g.., did not work)
1
In the 7 days prior to becoming ill with swine flu, on which unit types did you work?
(please indicate number of days worked in each category):
____Inpatient adult critical care (e.g., intensive care unit)
____Neonatal/pediatric critical care
____Inpatient adult ward (non-critical care)
____Inpatient pediatric ward (non-critical care)
____Operating room
____Outpatient clinic
____Emergency department
____Obstetrics or labor and delivery
____Other, specify: ____________________________________________________
____None (e.g., did not work)
____Not applicable
Healthcare Exposures
In the 7 days prior to becoming ill with swine flu, did you enter a patient’s room while the patient was present? ( if no
skip to Medical History Section)
_____Yes
_____No
In the 7 days prior to becoming ill with swine flu, did you have physical contact with any patient(s)?
_____Yes
_____No
In the 7 days prior to becoming ill with swine flu, did you enter the room of a patient (while the patient was present)
with any of the following respiratory illnesses (check ALL THAT APPLY):
___ Pneumonia
___ Upper respiratory tract infection
___ Flu-like symptoms
___ Don’t know
If yes, please indicate how often you used the following personal protective equipment upon entering their room:
a. gloves
Never
Some of the time
Most of the time
Always
b. gowns
Never
Some of the time
Most of the time
Always
c. surgical mask
Never
Some of the time
Most of the time
Always
d. N-95 respirator
Never
Some of the time
Most of the time
Always
e. face shield or
Never
Some of the time
Most of the time
Always
goggles
In the 7 days prior to becoming ill with swine flu, did you enter the room of any patient with swine flu (while the
patient was present)?
_____Yes _____No
If yes, please indicate how often you used the following personal protective equipment upon entering their room:
a. gloves
Never
Some of the time
Most of the time
Always
b. gowns
Never
Some of the time
Most of the time
Always
c. surgical mask
Never
Some of the time
Most of the time
Always
d. N-95 respirator
Never
Some of the time
Most of the time
Always
e. face shield or
Never
Some of the time
Most of the time
Always
goggles
Medical History
Are you taking any medication that might suppress your immune system (for example, prednisone or cyclosporine)
___ Yes ___ No ___ Don’t know,
Specify medication: ___________________________________
Do you have an autoimmune disease ___ Yes ___ No ___ Don’t know
Are you a current smoker? ___Yes
___No
Outcomes
How many days did you take off from work due to your swine flu illness?
________
2
Page of 2