Influenza Healthcare Worker Case Report Addendum Form printable pdf download

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)

Influenza Healthcare Worker Case Report Addendum Form

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