Case Report Form - U.s. Department Of Health And Human Services (Page 3 of 13) in pdf

CDC Listeria Initiative Case Report Form

PulseNet ID or state public health lab isolate ID ____________________________

State epi case ID ___________________

Local epi case ID ____________________

Date form completed:

FoodNet ID (if applicable) _______________________________

NNDSS ID (if available) ___ ___ ___ ___ ___

Name of interviewer

first name

last name

Was the isolate sent to public health laboratory? £ Yes £ No £ Unknown

If No, why not, and could it still be obtained? ________________________

BOX 1: Case-patient demographic data

State of residence ___ ___

County _______________

Age _____ (if pregnancy-associated, use age of mother)

Sex £ Male £ Female £ Unknown

Ethnicity: Is the case-patient of Hispanic, Latino, or Spanish origin? (one or more categories may be selected)

£ Yes ----------------------------------------------------> If yes:

£ Mexican, Mexican American, Chicano

£ Another Hispanic, Latino, or Spanish origin (specify)

£ No

£ Puerto Rican

______________________

£ Unknown

£ Cuban

£ Unknown Hispanic ancestry/declined to specify

£ Declined to answer

Race (One or more categories may be selected)

£ African American/Black

£ Asian (specify)

£ White (specify)

£ Asian Indian

£ Middle Eastern/North African

£ Native American Indian or Alaska Native

£ Chinese

£ Not Middle Eastern/North African

£ Native Hawaiian or other Pacific Islander (specify)

£ Filipino

£ Unknown

£ Native Hawaiian

£ Japanese

£ Guamanian or Chamorro

£ Other (specify) _____________________

£ Korean

£ Samoan

£ Vietnamese

£ Declined to answer

£ Other Pacific Islander

£ Other Asian (specify) _________________

BOX 2: Is the Listeria case associated with pregnancy? (Illness in pregnant woman, fetus, or infants ≤60 days old)

£ Yes If yes, skip to Box 4.

£ No

£ Unknown

BOX 3: Cases not associated with pregnancy (Illness in non-pregnant adults and children >60 days old)

Type(s) of specimen(s) that grew Listeria

Specimen collection date

State public health lab isolate ID #

(check all that apply)

(mm/dd/yyyy)

(Important: must have at least one, if available)

£ Blood

____/____/____

£ CSF

____/____/____

£ Other (specify)

____/____/____

£ Other (specify)

Did patient have any of the following type(s) of illnesses related to the Listeria infection? (check all that apply)

£ Bloodstream infection/sepsis £ Meningitis

£ Meningoencephalitis £ Brain abscess £ Rhombencephalitis £ Peritonitis £ Pneumonia £ Wound infection

£ Joint infection/septic arthritis £ Bone infection/osteomyelitis £ Unknown £ Other (specify) _______________________________________

Was patient hospitalized for listeriosis? £ Yes £ No £ Unknown

If yes: Admit date:

Discharge date:

£ Still hospitalized as of:

Patient’s outcome: £ Survived £ Died £ Unknown

Date of death:

If died: Was listeriosis or Listeria infection listed on death certificate? £ Yes £ No £ Unknown

If survived: Last known date alive?

BOX 4: Cases associated with pregnancy (Illness in pregnant woman, fetus, or infants ≤60 days old)

Type(s) of specimen(s) that grew Listeria

Specimen collection date

State public health lab isolate ID #

(check all that apply)

(

)

(Important: must have at least one, if available)

yyyy

£ Blood from mother

____/____/____

£ Blood from infant

____/____/____

£ CSF from mother

____/____/____

£ CSF from infant

____/____/____

£ Placenta

____/____/____

£ Amniotic fluid

____/____/____

£ Fetal tissue

____/____/____

£ Other (specify)

____/____/____

£ Other (specify)

____/____/____

Case Report Form - U.s. Department Of Health And Human Services Page 3

Related Articles

Related forms

Related Categories