U.S. DEPARTMENT OF

HEALTH AND HUMAN SERVICES

CENTERS FOR DISEASE CONTROL

AND PREVENTION

ATLANTA, GA 30329-4027

Tularemia Case Investigation Report

OMB No. 0920-0728 Case ID #:

Patient History

Age: Sex: Patient Ethnicity: Patient race: (select all that apply)

Female Hispanic or Latino American Indian/Alaska Native Native Hawaiian or Pacific Islander

Male Not Hispanic or Latino Asian White

Unknown Unknown Black or African American Unknown/other

Residence:

State:

County:

Concurrent conditions:

Pregnant

Immunocompromised (please specify):

Course of Current Illness

Date of initial symptom onset: 

mm/dd/yyyy

Date first seen by a medical person: 

Was the patient hospitalized? Yes No Unknown

Admit date:

mm/dd/yyyy

Discharge date:

mm/dd/yyyy mm/dd/yyyy

Symptoms at presentation: 

Fever/sweats/chills Yes No Unknown Cough Yes No Unknown

Confusion/delirium Yes No Unknown Chest Pain Yes No Unknown

Vomiting/diarrhea/abdominal pain Yes No Unknown Shortness of breath Yes No Unknown

Sore throat Yes No Unknown Other:

Localized signs: 

Lymphadenopathy Yes No Unknown

Location/description:

Skin lesions (e.g., ulcer, papules) Yes No Unknown

Location/description:

Conjunctivitis Yes No Unknown

Pharyngitis/tonsillitis Yes No Unknown

Chest X-ray: Not Done Unknown Infiltrates or nodules Pleural effusion Clear/normal

Treatment:

Receipt of effective antibiotics (check all that were administered):

Aminoglycosides start date:

(e.g., streptomycin, gentamicin) mm/dd/yyyy

Tetracyclines start date:

(e.g., doxycycline) mm/dd/yyyy

Fluoroquinolones start date:

(e.g., ciprofloxacin, levofloxacin)

Illness outcome:

Recovered, no complications

Recovered, complications (please specify): 

mm/dd/yyyy

Recovered, unknown complications

Died (please specify cause and date of death): 

Unknown

Primary clinical syndrome: 

Ulceroglandular Oculoglandular Typhoidal Meningitic

Glandular Oropharyngeal Pneumonic Unknown 

Public reporting burden of this collection of information is estimated to average 20 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 

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Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to 

CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30329-4027; ATTN: PRA (0920-0728).

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Laboratory Evidence of Infection

Detection or Isolation

F. tularensis cultured? Yes No Unknown

Specimen source

(e.g., blood, wound swab) 

Date specimen collected

mm/dd/yyyy

If not cultured, presence of F. tularensis detected?

Yes No Unknown

Specimen source Date specimen collected

mm/dd/yyyy

Test performed (e.g., DFA or PCR)

Serology: 

None Single positive titer ≥4-fold change in titer

Serum 1:

Date drawn 

F. tularensis subspecies:

Type A (i.e., tularensis) Type B (i.e., holarctica) Unknown

mm/dd/yyyy

Titer: 

Serum 2:

Date drawn 

mm/dd/yyyy

Titer: 

Tularemia Case Status

Confirmed A clinically-compatible case with either F. tularensis cultured from a clinical specimen or ≥4-fold change in serum 

antibody titer

Probable A clinically-compatible case with either detection (not isolation) of F. tularensis in a clinical specimen or a single 

positive antibody titer (or <4-fold change in titer)

Not a case

Epidemiologic Investigation

Was this illness epi-linked to any other tularemia cases? Yes No Unknown Specify:

Was this illness associated with travel? Yes No Unknown Specify:

Possible routes of exposure: In the 2 weeks preceding illness, did the patient report:

Animal contact? Yes No Unknown

If yes, type of animal Wild (specify: ) Domestic pet (specify: )

What was the nature of the contact? Bitten Scratched Disposed/handled deceased animal 

Cleaned carcass Consumed hunted game meat 

Tick or deerfly bite? Tick Deerfly No Unknown insect type

Contact with or ingestion of untreated water? Yes No Unknown

Environmental aerosol-generating activities (e.g., brush-cutting, lawnmowing, high-pressure spraying)?

Yes No Unknown (If yes, specify: )

Other exposure: specify

Additional comments: 

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