REPORT FORM: Adult Influenza Associated Deaths FOR 2009 ...
REPORT FORM: Adult Influenza Associated Deaths FOR 2009-2010 INFLUENZA SEASON
(For use by Local Health Departments only)
Date of report: ____/____/________ Jurisdiction: ______________________
LHD contact person: ______________________________________________
Name : ______________________________ DOB: __________________
Address:_______________________________________________________
Ethnicity: _____________________________ Gender: M / F
|Event |Date (If Applicable) |
|Onset of symptoms | |
|ED/ Physician Visit | |
|Hospital admission | |
|Death | |
Name of Hospital admitted to: ________________________________________
ICU: Yes/ No Start Date: __________________
Intubation: Yes/ No Start Date: __________________
Antiviral Treatment: Yes/ No Start Date: __________________
|Lab Test |Result |Date Collected |Location where test was done |
|Rapid antigen |( Influenza A | | |
| |( Influenza B | | |
| |( Influenza A H1N1 | | |
| |( Influenza (unspecified) | | |
|Culture |( Influenza A | | |
| |( Influenza B | | |
| |( Influenza A H1N1 | | |
| |( Influenza (unspecified) | | |
|PCR |( Influenza A | | |
| |( Influenza B | | |
| |( Influenza A H1N1 | | |
| |( Influenza (unspecified) | | |
|Other: |( Influenza A | | |
| |( Influenza B | | |
| |( Influenza A H1N1 | | |
| |( Influenza (unspecified) | | |
Previously Vaccinated: Seasonal: Yes/ No Date: ______________
H1N1: Yes/ No Date: ______________
Pregnant: Yes/ No
Obese (BMI greater than 30): Yes/ No
Underlying Conditions (please list) _______________________________________
Cause of Death: _____________________________________________________
Bacterial Co-Infections: Yes/ No (please specify organism) _____________
Autopsy: Yes/ No Date: ________________
Family/next of kin notified? Yes/ No Date: ________________
Please attach all lab and medical records pertinent to investigation as well as case report form and fax to 410-669-4215.
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