Case Report Form - U.s. Department Of Health And Human Services printable pdf download

Case Report Form - U.s. Department Of Health And Human Services

U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES

CENTERS FOR DISEASE CONTROL AND PREVENTION

CDC Listeria Initiative

Case Report Form

Version 2.0

Please complete this questionnaire for all laboratory-confirmed listeriosis cases.

Instructions are available in a separate two-page document.

Please remove this page before submitting form to CDC

State public health laboratory isolate ID:

_______________________________________________________________

Patient’s name: _________________________________

Date of Birth:

Address: ___________________________________________________________________________

City: _______________________________ State: ___ ___ Zip: ___ ___ ___ ___ ___

Phone numbers: (h) ____________________

(w) _____________________

(m) ________________________

Hospital: _____________________________

Hospital: _____________________________ (if >1 hospital)

Hospital contact: _________________________________

Phone: ___________________________

If surrogate interview:

Interviewee name: ___________________________________

Interviewee phone number(s): ____________________________

_____________________________

Public reporting burden of this collection of information is estimated to average 30 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/ASTSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia, 30329; ATTN: PRA (0920-0728).

Form Approved - OMB No. 0920-0728