First Middle Initial 

Facility: (If hospitalized) 

 

Present Address: 

 

 

If yes, describe symptoms, time period of symptoms, and relationship to this patient: 

 

 

 

 

 

 

SAMPLE SHORT DATA COLLECTION FORM 

(FOR INVESTIGATOR’S USE) 

Today’s Date (month, day, year) _____/_____/_____ Initials of person completing form: ____________ 

Location (state/city) of outbreak ________________________ 

PATIENT INTERVIEW CASE ID:________________________
 

1. Patient identifying information 

Name _____________________________ __________________________ _________

 Last 

Date of Birth: 

Month Day Year 

Sex: Male 

Female 

Age:_____ yr 

mo 

Race: White 

Black 

Asian/Pacific Islander 

Unknown 

Other _____________________ 

Name ________________ _______________ __ 

City ________________________________ ___ 

County ________________ ________________ 

State _____ Phone number ________________ 

Medical Record #: ________________ _______ 

Facility Name (if applicable) ______________ 

Street _____________________________ 

City ___________ 

County _________ _______________ State ______ 

Yes No Unknown 

Hispanic or Latino: 

2. Symptoms, Signs and Significant Conditions 

Date of symptom onset: 

Month Day Year 

Date of first presentation for medical care: 

Month Day Year 

Does the patient have: 

Fever (subjective) 

Cough 

If yes, productive? 

Blood in sputum 

Difficulty breathing 

Wheeze 

Runny nose 

Sore throat 

Headache 

Stiff neck 

Sneezing 

Nasal congestion 

Shortness of breath 

Muscle aches 

Sweats 

Abdominal pain 

Chills/Rigors 

Diarrhea 

Vomiting 

Rash 

Red or draining eyes 

Weight loss over past 3 months 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

3. Exposure History 

Do you know of others who have been ill with similar symptoms? 

Has the patient been exposed to any animals/insect bites in the last 10 days?

 If yes, describe 

Has the patient been traveling (overnight or day trip) in the last two weeks?:

 If yes, describe 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

4. General Notes/Comments 

Revised: June 30, 2008 ACUTE RESPIRATORY ILLNESS OUTBREAK DATA COLLECTION FORM SHORT FORM 

1 

U.S. Department Health & Human Services | Centers for Disease Control and Prevention 
Child <5 years: RR > 40 

Infant: RR > 50 

Lower chest indrawing 

 

 

 

Admitted to hospital 

 If yes, date admitted: Still hospitalized? 

Discharged? 

 

Supplemental oxygen 

Mechanical ventilation 

 

 

 

8.Laboratory Results 

If yes, check all that apply: 

 

 

SAMPLE SHORT DATA COLLECTION FORM (FOR INVESTIGATOR’S USE) 

CHART REVIEW/CLINICAL DATA
 

5. Clinical Data 

Did the person have: 

Temp >38.0 

Adult Respiratory rate (RR) >25 

 If age < 5 years: 

Pulse Ox <95% 

Wheeze 

Crackles/Rhonchi 

Hypotension 

Cyanosis 

Altered mental status 

Meningismus or nuchal rigidity 

Headache 

Rash 

Lymphadenopathy 

Poor feeding 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Past Medical History (Check all that apply): 

Immunocompromised 

COPD 

HIV/AIDS 

Congestive heart failure 

Diabetes 

Tuberculosis (if yes, Latent Active) 

Current smoker 

Asthma 

IV drug use 

Other ___________________ 

______________ 

___________________ 

6. Treatment 

Was the patient: 

Month Day Year 

Outcome: 

Died? 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Yes No Unknown 

Required: 

 Yes No Unknown 

Yes No Unknown 

Received antibiotics? 

If yes, antibiotic(s): 

Received antivirals? 

If yes, antiviral(s): 

Yes No Unknown

Yes No Unknown 

7. Laboratory Testing 

Specimens collected and test requested: 

Sputum: Gram stain/Culture 

AFB 

Fungal stain or culture 

Swabs: Nasopharyngeal 

Nasal-Pertussis (special media required) 

Oropharyngeal 

Blood: Culture 

Serology 

If yes: 

Urine: Legionella antigen 

Pneumococcal antigen 

Histoplasma antigen 

Fluid: Bronchoalveolar Lavage 

Pleural 

Other: __________________________

Type of Specimen Date of Collection Tests Performed Results 

9.Radiological Testing 

Was a chest X-ray or chest CT scan performed? 

Normal 

Lobar consolidation or dense infiltrate 

Pleural effusion 

Yes No Unknown 

Admitted to ICU 

Yes No Unknown 

Cavitary lesion or blebs 

Interstitial infiltrate 

Other ___________________________ 

acute 

convalescent 

Revised: June 30, 2008 ACUTE RESPIRATORY ILLNESS OUTBREAK DATA COLLECTION FORM 

2 

U.S. Department Health & Human Services | Centers for Disease Control and Prevention