Lung Injury Associated with E-cigarette Use or Vaping | National Case Report Form 

CDC is investigating cases of unexplained lung injury associated with electronic cigarette use or vaping as detailed in CDC’s Health Advisory

(https://emergency.cdc.gov/han/han00421.asp). Local and state health departments should complete this form for any probable or confirmed

case patient (see case definition) and transmit data to CDC using DCIPHER or by contacting CDC State Points of Contact. 

CDC Case ID Number _________________________ Medical Record Number ___________________________________

Case status ☐ Probable ☐ Confirmed Died? ☐ Yes ☐ No If yes, date of death _____________ (see clinical section) 

Date form completed Name of Public Health Department ________________ 

Person completing form Contact phone number 

PART I: PATIENT DEMOGRAPHICS AND EXPOSURES

Patient Demographics

County __________________ State _____________________ Gender ☐Male ☐ Female ☐ Other Age _________years 

Race ☐White ☐Black ☐American Indian/Alaska Native ☐Asian ☐Native Hawaiian or Other Pacific Islander ☐Other

Ethnicity ☐Hispanic ☐ Non-Hispanic ☐Other 

Patient Substance Use in the Past 3 Months (90 days)

Any e-Cigarette use or vaping (e.g., vaping, dabbing)? ☐ Yes ☐ No ☐ Refused to answer 

 If yes, any e-Cigarette use or vaping in the past month (30 days)? ☐ Yes ☐ No 

 If yes, substance(s) used in past 3 months (90 days)?

 ☐ Nicotine ☐ Marijuana, THC oil, THC concentrates, hash oil, wax ☐ Cannabidiol (CBD) ☐ Synthetic Cannabinoids ☐ Flavors alone 

 ☐ Other substances, specify _____ ☐ Unknown 

Any combustible tobacco smoking (e.g., cigarettes, cigars)? ☐Yes ☐No Any other tobacco products (e.g., smokeless tobacco)? ☐Yes ☐No

Any combustible marijuana smoking (i.e., any non-vape marijuana)? ☐Yes ☐No Any other marijuana products (e.g., edibles)? ☐Yes ☐No

Any nicotine e-cigarette use or vaping reported? ☐ Yes ☐ No Date last used 

If yes, what is the frequency of use? ☐ Daily ☐ A few times per week, specify: _________ ☐ A few times per month, specify ______ 

☐ Monthly or less [Skip logic: On average, how many times per day? __________ ]

Did patient report using flavoured nicotine in e-Cigarette and/or vape product(s)? ☐ Yes ☐ No 

How many brands of nicotine containing products vaped or dabbed in the past 3 months? _____ [enter whole number]

Where was the nicotine e-Cigarette(s) or vaping product(s) purchased or obtained? Check all that apply 

 ☐ Medical dispensary ☐ Recreational dispensary (retail cannabis/marijuana shop) ☐ Vape shop ☐ Pop-up shop 

 ☐ Convenience store/gas station ☐ Family or friend ☐ Illicit dealer ☐ Online ☐ Other, describe _____________ 

What kind of device(s) were used with this product? Select all that apply

 ☐ Disposable e-cigarette ☐ E-cigarettes with pre-filled cartridges ☐ E-cigarette with tank that you refill with liquids (e.g. mods) 

 ☐ E-cigarettes with pre-filled or refillable “pods” or pod cartridges (e.g. JUUL, Suorin) ☐ Other, describe ___________

Was this a mod device (a device that allows user to choose higher and/or variable temperatures)? ☐ Yes ☐ No ☐ Unknown 

Did patient modify, or add a substance, to the device(s) that was not intended by the manufacturer? ☐ Yes ☐ No ☐ Unknown 

 If yes, explain __________________________________________________________________________________

Did patient share product with anyone who became ill? ☐ Yes ☐ No 

Product sample sent for testing? ☐ Yes ☐ No If yes, where was sample tested _ Product sample ID number(s) __________

Any THC e-cigarette use or vaping reported? ☐Yes ☐No Date last used

 If yes, what is the frequency of use? ☐ Daily ☐ A few times per week, specify: _________ ☐ A few times per month, specify________ 

 ☐ Monthly or less [Skip logic: On average, how many times per day? __________ ]

Did patient report using flavoured THC in e-Cigarette and/or vape product(s)? ☐ Yes ☐ No 

How many brands of THC containing products vaped or dabbed in the past 3 months? _____ [enter whole number]

What was the purpose of THC product(s) use? ☐ medical purposes ☐ nonmedical (recreational) purposes ☐ other, specify ____ 

Which THC substance(s) were used in an e-cigarette, vaping device, vaporizer, or dab rig? Select all that apply

 ☐ Marijuana herb ☐THC oils ☐Butane hash oil ☐THC concentrate (e.g., wax, batter/budder, crumble, shatter, pull and snap)

 ☐THC powder (e.g., dry sift) ☐ Other, describe ___________

Where was the THC e-Cigarette(s) or vaping product(s) purchased or obtained? Check all that apply 

 ☐ Medical dispensary ☐ Recreational dispensary (retail cannabis/marijuana shop) ☐ Vape shop ☐ Pop-up shop 

 ☐ Convenience store/gas station ☐ Family or friend ☐ Illicit dealer ☐ Online ☐ Other, describe _____________ 

What kind of device(s) were used with this substance? Select all that apply

 ☐ Disposable device ☐ Device with pre-filled cartridges ☐ Device with tank that you refill with liquids (e.g., mods) 

 ☐ Device with pre-filled or refillable “pods” or pod cartridges (e.g. JUUL, Suorin) ☐ Dab rig ☐ Vaporizer (for dry herbs, etc.) ☐ Other ____

What kind of THC cartridge(s) were used with device(s): ☐ Rove ☐ Dank Vapes ☐ Golden Gorilla ☐ Smart Cart ☐ Other ____________ 

Was this a mod device (a device that allows user to choose higher and/or variable temperatures)? ☐ Yes ☐ No ☐ Unknown 

Did patient modify, or add a substance, to the device(s) that was not intended by the manufacturer? ☐ Yes ☐ No ☐ Unknown 

 If yes, explain __________________________________________________________________________________ 

Product sample sent for testing? ☐ Yes ☐ No If yes, where was sample tested _ Product sample ID number(s) ______

PART II: CLINICAL INFORMATION

Symptoms at Initial Presentation to Medical Care

Chief complaint Date symptom(s) started

GI symptoms? ☐ Yes ☐ No ☐ Unknown If yes, describe _________

Respiratory symptoms? ☐ Yes ☐ No ☐ Unknown If yes, describe _________
Constitutional symptoms? ☐ Yes ☐ No ☐ Unknown If yes, describe __________

 (e.g., fever, chills, malaise)

Weight loss during current illness? ☐ Yes ☐ No ☐ Unknown If yes, amount (lb)

Medical History

Chronic respiratory disease (including asthma, COPD, etc.)? ☐ Yes ☐ No If yes, specify type of disease

Heart disease? ☐ Yes ☒ No If yes, specify type of disease 

Anxiety? ☐ Yes ☐ No

Depression? ☐ Yes ☐ No

Other chronic illness? ☐ Yes ☐ No If yes, specify type of chronic illness 

Pregnant? ☐ Yes ☐ No ☐ Unknown If yes, trimester ☐ First ☐ Second ☐ Third ☐ Unknown 

Imaging

Chest imaging performed ☐ CT chest ☐ Chest X-ray ☐ Both

Location of abnormal findings ☐ Bilateral ☐ Right ☐ Left ☐ Normal (no findings)

Infiltrates/opacities present ☐ Yes ☐ No

Subpleural sparing on CT ☐ Yes ☐ No ☐ Unknown

Specify other abnormal chest imaging findings (e.g., pneumothorax)_________________

Infectious Disease Testing

Respiratory viral panel ☐ Positive (specify _________ ) ☐ Negative ☐ Pending ☐ Not done

Influenza ☐ Positive (specify _________ ) ☐ Negative ☐ Pending ☐ Not done

Blood cultures ☐ Positive (specify organisms_____) ☐ Negative ☐ Pending ☐ Not done

Legionella urinary antigen ☐ Positive ☐ Negative ☐ Pending ☐ Not done

Strep pneumoniae urinary antigen ☐ Positive ☐ Negative ☐ Pending ☐ Not done

Mycoplasma pneumoniae ☐ Positive (specify _________ ) ☐ Negative ☐ Pending ☐ Not done

Other ☐ Specify __________________

Clinical Course of Lung Injury

Is this the first time patient is presenting for clinical care for these symptoms? ☐ Yes ☐ No If yes, is a follow-up visit scheduled? ☐ Yes ☐ No 

Was patient hypoxemic at any outpatient, urgent care or ED visit? ☐ Yes ☐ No If yes, date(s)________ Lowest value: ___________ 

Outpatient visit #1 ☐ Yes ☐ No If yes, date of visit _______ Outpatient visit #2 ☐ Yes ☐ No If yes, date of visit ______

Were there additional outpatient/clinic visits? ☐ Yes ☐ No If yes, specify number of additional visits _______

Urgent care visit #1 ☐ Yes ☐ No If yes, date of visit ____ Urgent care visit #2 ☐ Yes ☐ No If yes, date of visit _______

Were there additional urgent care visits? ☐ Yes ☐ No If yes, specify number of additional visits _______

Emergency Department (ED) visit #1 ☐ Yes ☐ No If yes, date of visit _______ 

 ED visit #2 ☐ Yes ☐ No If yes, date of visit ________

 Were there additional ED visits? ☐ Yes ☐ No If yes, specify number of additional visits _______

Hospitalization #1 ☐ Yes ☐ No If yes, hospitalization date __________ Discharge date ________

Hospitalization #2 ☐ Yes ☐ No If yes, hospitalization date __________ Discharge date ________

Were there additional hospitalizations? ☐ Yes ☐ No If yes, specify number of additional hospitalizations _______ 

ICU Admission ☐ Yes ☐ No If yes, ICU admission date _________ ICU duration (in days) __________

Treated with steroids? ☐ Yes ☐ No If yes, medication: ________ dose: ____ start date:______ duration: __ ☐ Taper

Treated with antibiotics? ☐ Yes ☐ No If yes, medication: ________ dose: ____ start date:______ duration:________

Treated with antivirals? ☐ Yes ☐ No If yes, medication: ________ dose: ___ _ start date:______ duration:________ 

Required respiratory support? ☐ Intubated (duration_________) ☐ BiPAP/CPAP/High flow

Required ECMO (Extracorporeal membrane oxygenation)? ☐ Yes (duration_________) ☐ No 

Clinical specimens

Bronchoalveolar lavage performed? ☐ Yes, date of sample_____ ☐ No If yes, where tested _________________ Specimen ID _______

 If yes, lipid staining ☐ Yes ☐ No 

 If yes, lipid-laden macrophages seen ☐ Yes ☐ No 

Blood sample available for testing? ☐ Yes, date of sample ____ ☐ No If yes, where tested _________________ Specimen ID _______

Urine sample available for testing? ☐ Yes, date of sample ____ ☐ No If yes, where tested _________________ Specimen ID _______

Lung biopsy performed? ☐ Yes, date of sample ____ ☐ No If yes, where tested _________________ Specimen ID _______

 If yes, lipid staining ☐ Yes ☐ No 

 If yes, lipid-laden macrophages seen ☐ Yes ☐ No 

 If yes, findings consistent with acute lung injury? ☐ Yes ☐ No If no, specify findings __________________

 If yes, other significant findings __________________

Death Information

Died ☐ Yes ☐ No If yes, specify location_______________ Date of death _______________ 

Immediate cause of death ____________________________ Contributing causes of death ____________________________

Autopsy performed? ☐ Yes ☐ No If yes, autopsy sample collected ☐ Yes ☐ No If yes, where tested______ Specimen ID ________

 If yes, lipid staining performed on autopsy lung tissue ☐ Yes ☐ No If yes, lipid-laden macrophages seen ☐ Yes ☐ No 

 If yes, findings consistent with acute lung injury? ☐ Yes ☐ No If no, specify findings _________________

 If yes, other significant autopsy findings ___________________

National Case Report Form v.01 Last updated October 16, 2019

FOR PRINT ONLY