Legionellosis Case Report
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1
2Reset Patient ID Info
Patient’s Name: ____________________________________________________ Telephone Number: ________________ Hospital: ___________________
LAST / FIRST / MI
Address: _________________________________________________________________
___________________Patient Chart No.: __________________
NUMBER / STREET / APT NO / CITY / STATE
ZIP CODE
PATIENT IDENTIFIER INFORMATION IS NOT TRANSMITTED TO CDC
Form Approved OMB No. 0920-0728
CDC • National Center for Immunization and Respiratory Diseases
LEGIONELLOSIS CASE REPORT
Reset Form
(DISEASE CAUSED BY ANY LEGIONELLA SPECIES)
Department of Health & Human Services
☐☐☐☐☐☐
Case No.:
Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, 30329-4027
(CDC use only)
PATIENT INfORmATION
1. State Health Dept. Case No.: 2. Reporting State:
3. County of Residence:
5. Occupation:
4. State of Residence:
☐☐
☐☐
8. Ethnicity:
9. Race:
7. Sex:
6a. Date of Birth:
6b. Age:
□
(check all that apply)
1
Black or African American
□
1
Days
American Indian/
☐☐ ☐☐ ☐☐☐☐ ☐☐☐
Native Hawaiian or
□
□
□
1
□
□
□
1
Male
1
Hispanic/Latino
9
Unknown
1
2
Mos.
Alaska Native
Other Pacific Islander
□
Mo.
Day
Year
3
Years
□
□
□
□
□
2
Not Hispanic/Latino
1
Asian
2
Female
1
White
1
Unknown
CLINICAL ILLNESS
10. Diagnosis:
11. Date of symptom
12. Date of first report to
(check one)
onset of legionellosis:
public health at any level:
☐
1
Legionnaires’ Disease (pneumonia, clinical or X-ray diagnosed)
☐
☐☐ ☐☐ ☐☐☐☐
☐☐ ☐☐ ☐☐☐☐
2
Pontiac Fever (fever and myalgia without pneumonia)
☐
Mo.
Day
Year
Mo.
Day
Year
8
Other (e.g., endocarditis, wound infection): _____________________
13. Was the patient hospitalized during treatment for legionellosis?
14. Outcome of illness:
□
□
□
1
Yes 2
No 9
Unknown
□
3
Still ill
1
□
Survived
☐☐ ☐☐ ☐☐☐☐
Hospital name: ____________________________________________
If yes, date of admission:
□
□
9
Unknown
2
Died
Mo.
Day
Year
City, State: _______________________________________________
ExPOSuRE INfORmATION
15. In the 10 days before onset, did the patient spend any nights away from home (excluding healthcare settings)?
1
Yes* 2
No 9
Unknown
If yes, please complete the following table.
□
□
□
(check one)
dAtes of stAy
room
AccommodAtion nAme
Address
city
stAte
Zip
country
number
ArrivAl
depArture
*If yes, was this case reported to CDC at travellegionella@cdc.gov?
□
□
□
1
Yes 2
No 9
Unknown
16. In the 10 days before onset, did the patient get in or spend time near a whirlpool spa (i.e., hot tub)?
1
Yes 2
No 9
Unknown If yes, describe where: _________________________ If yes, list dates: ________________________
□
□
□
(check one)
17. In the 10 days before onset, did the patient use a nebulizer, CPAP, BiPAP or any other respiratory therapy equipment for the treatment of sleep
apnea, COPD, asthma or for any other reason?
1
Yes 2
No 9
Unknown If yes, does this device use a humidifier? 1
Yes 2
No 9
Unknown
□
□
□
□
□
□
(check one)
If yes, what type of water is used in the device? (check all that apply) 1
Sterile 1
Distilled 1
Bottled 1
Tap 1
Other 1
Unknown
□
□
□
□
□
□
18. In the 10 days before onset, did the patient visit or stay in a healthcare setting (e.g., hospital, long term care/rehab/skilled nursing facility, clinic)?
1
Yes 2
No 9
Unknown
If yes, please complete the following table.
□
□
□
(check one)
is tHis
dAte of visit /
type of HeAltHcAre
type of exposure
nAme of
fAcility Also
Admission
setting / fAcility
reAson for visit
city
stAte
fAcility
A trAnsplAnt
(cHeck one)
(cHeck one)
center?
stArt dAte
end dAte
□
□
□
1
Hospital
1
Inpatient
1
Yes
□
□
□
2
Long term care
2
Outpatient
2
No
□
□
□
3
Clinic
3
Visitor or volunteer
9
Unknown
□
□
8
Other: ______________
4
Employee
□
□
□
1
Hospital
1
Inpatient
1
Yes
□
□
□
2
Long term care
2
Outpatient
2
No
□
□
□
3
Clinic
3
Visitor or volunteer
9
Unknown
□
□
8
Other: ______________
4
Employee
Public reporting burden of this collection of information is estimated to average 20 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, Project Clearance Officer, 1600 Clifton Road,
MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0009). Do not send the completed form to this address. While your response is voluntary your cooperation is necessary for the understanding and control of this disease.
CDC 52.56 Rev. 11/2013
Legionellosis Case Report
Page 1 of 2
CDC 52.56 (E), January 2014, CDC Adobe Acrobat 10.1, S508 Electronic Version, January 2014
CS218324
– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –
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