Form Cdc 54.48 - Cyclosporiasis Surveillance Case Report Form
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Form approved
OMB No. 0920-0009
CYCLOSPORIASIS SURVEILLANCE CASE REPORT FORM
Demographic data:
Patient’s name (first 4 letters of last name):
________
Sex:
Male
Female
State of residence: _________ County: ________________
Age: ____ Date of birth (mm/yyyy): ________
Ethnic origin:
Race (check all that apply):
Hispanic or Latino
White
American Indian or Alaska Native
Not Hispanic or Latino
Black or African American
Native Hawaiian or other Pacific Islander
Unknown
Asian
Unknown
Physician’s name: ______________________________________________
Phone: _____________ FAX: _____________ Email: ______________________________
Clinical data:
(For dates, be as specific as possible. However, approximations [e.g., mm/yyyy] are okay.)
Date of onset of illness / symptoms: __________
(
Unknown date; unable to approximate)
Signs and symptoms:
Diarrhea:
Yes
No
Unknown
Fatigue:
Yes
No
Unknown
If yes, maximum number stools per day: __________
Anorexia:
Yes
No
Unknown
(unknown = 999)
Nausea:
Yes
No
Unknown
Vomiting:
Yes
No
Unknown
Weight loss:
Yes
No
Unknown
Abdominal cramps:
Yes
No
Unknown
If yes, baseline weight: ______ lbs. (unknown = 999)
Number of pounds lost: ___________
Fever (or felt feverish):
Yes
No
Unknown
If yes, temperature: _______degrees F (unknown or not measured = 999)
Other symptoms (specify): ____________________________________________________________________
Hospitalized (at least overnight):
Yes
No
Unknown
If yes, name of hospital: _________________________________ Date of admission: __________
Date stool collected for Cyclospora testing: __________
(If multiple stools, specify below or on p. 2.)
Test results:
Positive
Negative
Unknown (or pending)
If known, specify testing methods and laboratories, including, if applicable, testing done by state or CDC labs:
______________________________________________________________________________________
Results from state lab (not applicable:
):
Positive
Negative
Unknown (or pending)
Results from CDC lab (not applicable:
):
Positive
Negative
Unknown (or pending)
Has the case-patient been treated (or is he/she being treated) for cyclosporiasis?
Yes
No
Unknown
If yes, what medication(s)?
Trimethoprim/sulfamethoxazole (e.g., Bactrim, Septra, Cotrim)
Other (specify): __________________________________________________
Unknown
Is case-patient allergic to (or intolerant of) sulfa drugs?
Yes
No
Unknown
Public reporting burden of this collection of information is estimated to average 15 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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333; ATTN: PRA (0920-0009).
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CDC 54.48 (E), Revised August 2010, CDC Adobe Acrobat 9.3, S508 Electronic Version, September 2010
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