Sample Short Data Collection Form
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2SAMPLE SHORT DATA COLLECTION FORM
(FOR INVESTIGATOR’S USE)
Today’s Date (month, day, year) _____/_____/_____
Initials of person completing form: ____________
Location (state/city) of outbreak ________________________
PATIENT INTERVIEW
CASE ID:________________________
1. Patient identifying information
Date of Birth:
Name _____________________________
__________________________
_________
Last
First
Middle Initial
Month
Day
Year
yr
Sex:
Male
Age:_____
Race:
White
Asian/Pacific Islander
Hispanic or Latino:
mo
Female
Black
Unknown
Yes
Other _____________________
No
Unknown
Facility: (If hospitalized)
Present Address:
Name ________________ _______________ __
Facility Name (if applicable) ______________
City ________________________________ ___
Street _____________________________
County ________________ ________________
City ___________
State _____ Phone number ________________
County _________ _______________ State ______
Medical Record #: ________________ _______
2. Symptoms, Signs and Significant Conditions
Date of first presentation for medical care:
Date of symptom onset:
Month
Day
Year
Month
Day
Year
Does the patient have:
Fever (subjective)
Nasal congestion
Yes
Yes
No
Unknown
No
Unknown
Yes
Unknown
No
Cough
Shortness of breath
Yes
No
Unknown
Yes
Yes
No
Unknown
No
Unknown
If yes, productive?
Muscle aches
Yes
Yes
No
Unknown
No
Unknown
Blood in sputum
Sweats
Yes
Yes
No
Unknown
No
Unknown
Difficulty breathing
Abdominal pain
Yes
Yes
Wheeze
No
Unknown
Chills/Rigors
No
Unknown
Yes
Unknown
Yes
Unknown
No
No
Runny nose
Diarrhea
Yes
Unknown
Yes
Unknown
Sore throat
No
Vomiting
No
Yes
Unknown
Yes
Unknown
No
No
Headache
Rash
Yes
Yes
Stiff neck
No
Unknown
Red or draining eyes
No
Unknown
Yes
Unknown
Yes
Unknown
Sneezing
No
Weight loss over past 3 months
No
3. Exposure History
Do you know of others who have been ill with similar symptoms?
Yes
Unknown
No
If yes, describe symptoms, time period of symptoms, and relationship to this patient:
Has the patient been exposed to any animals/insect bites in the last 10 days?
Yes
No
Unknown
If yes, describe
Has the patient been traveling (overnight or day trip) in the last two weeks?:
Yes
No
Unknown
If yes, describe
4. General Notes/Comments
Revised: June 30, 2008
A CU TE R ESP I R ATO RY IL L NE S S O UTBRE A K D ATA CO LLECTI ON FOR M
SHORT FORM
1
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U.S. Department Health & Human Services
Centers for Disease Control and Prevention
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