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Haemophilus influenzae Surveillance Worksheet 

(Expanded Worksheet Option) Local Use Only Appendix 4

CS106190

NAME (Last, First) Hospital Record No.

Address (Street and No.) City County Zip Phone

Reporting Physician/Nurse/Hospital/Clinic/LabPhone Address Phone

DETACH HERE and transmit only lower portion if sent to CDC

DEMOGRAPHIC INFORMATION

1. Patient Date of Birth hh	hh	hhhh MONTH DAY YEAR

hhh h	 2. Reported Age: YEARS

HOURS

WEEKS

h	DAYS

MONTHS

UNKNOWN

h	 h	

h	 h	

3. Sex h	MALE h	FEMALE h	UNKNOWN

4. Ethnicity h	HISPANIC h	NOT HISPANIC h	UNKNOWN

5. Race: h	American Indian or Alaska Native h	

Asian

Black or African-American

Native Hawaiian or Other Pacific Islander

White

Other

Unknown

h ___

h h	

h	

6. Identification Information as of hh	hh	h MONTH DAY YEAR

_____________________ Assigning Authority _____

h

 _________________________________

_________

hhh

Type _________

ID Value 

INVESTIGATION

INVESTIGATION SUMMARY

7. Jurisdiction: _________________

8. Program Area (state assigned): ___

9. State class ID number: ________

10. Investigation start date hMONTH DAY YEAR

11. Investigation status h Open Closed 

12. Share record with guests of this

jursidiction and program area?

___________________________

___________________________

___________________________

h	hh	hhhh

	 h	

h	 h	 Yes No

INVESTIGATOR

13. Last Name: ____________________________________________

14. First Name: ___________________________________________

15. E-mail: _______________________________________________

16. Investigation status hhh	hhh	hhhh	

17. Date assigned to investigation hh	hh	hhhh MONTH DAY YEAR

18. Type of insurance

h	MEDICARE h	

MILITARY/ VA 

MEDICAID/ STATE ASSISTANCE PROGRAM

INDIAN HEALTH SERVICE (IHS) 

PRIVATE/ HMO/PPO/MANAGED CARE PLAN 

h	

OTHER (SPECIFY)

NO HEALTHCARE COVERAGE

h	 h	 h	UNKNOWN

h	 h	 _________________________________________________________

19a. WEIGHT 1

____________lbs ____________oz OR ____________ kg h	unknown ____________

9b. HEIGHT

Ft _____________ in OR _____________ cm h	unknown

REPORTING SOURCE

20. Date of report hh	hh	hhhh MONTH DAY YEAR

21. Source name: __________________________________________

22. City: __________________________________________________

23. State: _______________________ Zip +4 ____________________

24. County: _______________________________________________

EARLIEST DATE REPORTED TO:

25. County: 26. State:

hh	hh	hhhh hh	hh	hhhh MONTH DAY YEAR MONTH DAY YEAR

REPORTER

27. Last name: 

28. First name: 

29. Person ID: 

 _______________________________________

 _______________________________________

________________________________________

30. E-mail: ___________________________________________

31. Telephone: hhh	hhh	hhhh

Extension: hhhh

CLINICAL

PHYSICIAN

32. Last name: ____________________________________________ 33. First name: _____________________________________________

34. E-mail: ________________________________ 35. Telephone: hhh	hhh	hhhh Extension: hhhh
HOSPITAL

36. Was the patient hospitalized for this illness?

h	Yes h	No h	UNKNOWN

37. Hospital name: _________________________________________

38. Hospital ID: ____________________________________________

39. Hospital ID Type: _______________________________________

40. Admission Date:

MONTH DAY YEAR

41. Discharge Date:

hh	hh	hhhh hh	hh	hhhh MONTH DAY YEAR

42.Total duration of stay within hospital: hhh	Days 

43a. Hospital/lab iD where culture 

identified:

43b. Hospital iD where patient 

treated:

hhhhh hhhhh

44a. Was patient transferred from 

another hospital? hhhhh h Yes h	No h	Unknown

44b. If Yes, hospital iD

45. Illness Onset Date:

MONTH DAY YEAR

hh	hh	hhhh hh	hh	hhhh

46. Illness End Date:

MONTH DAY YEAR

47. Types of infection caused by organism (CHECK ALL 

THAT APPLY)

Bacteremia

without focus

Meningitis

Otitis media

Pneumonia

Cellulitis

Epiglotitis

Hemolytic uremic 

syndrome (HUS)

h h Abscess (not skin)

Peritonitis

Pericarditis

Septic abortion

Chorioamnionitis

Septic arthritis

Osteomyelitis

h Empyema

Endocarditis

Endometritis

STSS

Necrotizing fasciitis

Puerperal sepsis

Other infection

h h h

h h h

h h h

h h h

h h h

h h h __________________________

48a. Bacterial species isolated from any normally sterile site 

(CHECK ALL THAT APPLY)

h Neisseria meningitidis h

Haemophilus influenzae

Group B streptococcus

Abscess (not skin)

Group A streptococcus

Streptococcus pneumoniae

h h

h h

48b. Other bacterial species isolated from any normally 

sterile site

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

49. Sterile sites from which organism isolated: (CHECK ALL 

THAT APPLY)

h Blood

CSF

Pleural fluid

Specify 

Internal body site 

h

Other normally sterile site 

Peritoneal fluid

Pericardial fluid

Joint

h Bone

h h h Muscle

h h

h ____________________________________________________

h _____________________________________________

50. Date first positive culture obtained: (date specimen drawn)

hh	hh	hhhh MONTH DAY YEAR

51. Other nonsterile sites from which organism isolated: (CHECK ALL 

THAT APPLY)

h Placenta

Amniotic fluid

Wound

h Middle ear

Sinus

Other nonsterile site 

52. Underlying causes or prior illness: (CHECK ALL THAT APPLY)

Current smoker

Multiple myleoma

Sickle cell anemia

Splenectomy / asplenia

Immunoglobulin deficiency

Immunosupressive therapy

(Steroids, Chemotherapy, Radiation)

Leukemia

Specify

h h Hodgkin disease

Asthma

Emphysema / COPD

Systemic lupus erythematosus (SLE)

Diabetes mellitus

Nephrotic syndrome

Renal failure/Dialysis

h HIV infection

AIDS or CD4 count <200

Cochlear implant

Deaf / profound hearing loss

Cirrhosis / Liver failure

Alcohol Abuse

Atherosclerotic Cardiovascular 

Disease (ASCVD) / (CAD)

h Heart failure / CHF

Obesity

CSF leak

IVDU

Cerebral vascular accident 

(CVA) / Stroke

Complement deficiency

h h h h

h h h h

h h h h

h h h h

h h h h

h h h

h Other malignancy

Organ transplant 

Other prior illness

________________________________________________________________________________________________________________________________

h ________________________________________________________________________________________________________________________________

h ________________________________________________________________________________________________________________________________

h h

h h ______________________________

53. Was patient pregnant / post partum at time of first positive culture? h	Yes h	No h	Unknown

If yes, outcome of fetus

h Survived, no apparent illness h

Survived, clinical infection

Live birth / neonatal death h

Abortion / stillbirth

Induced abortion

h h h Unknown

54. Is the patient <1 month of age? h	Yes h	No h	Unknown If yes, time of birth: _____:_____

Gestational age: hh(wks) Birth weight: hhhh(gms)

55. Did the patient die from this 

illness? h	Yes h	No 
56. What was the serotype?

h	a

b

c

h	d

e

f

h	Not Typable

Not Tested or Unknown

Other __________________

h	 h h	

h	 h	 h	

57. Was the patient <15 years of age at the time 

of the first positive cultureh	Yes h	No h	Unknown

58. Birth Country:

_________________________________________________________

59. Type of insurance: (CHECK ALL THAT APPLY)

h	Medicare

h Military/VA

Medicaid/state assistance program

Indian Health Service (IHS)

Private/HMO/PPO/managed care plan

No health care coverage

Unknown

h

h

h

h

h

h	Other Insurance ___________________________________

60. Is there a known previous contact with Hib disease within the preceding two months?h	Yes h	No h	Unknown

If yes specify type of contact: 

61. Significant past medical history: _______________________________________________________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

If pre-term birth (<37 weeks). Specify weeks: ________________

 __________________________________________________________________________________

Serum availability

Is acute serum available? h h o h 

Date:

MONTH DAY YEAR

hh	hh	hhhh

Is convalescant serum available? h	Yes h	No h	Unknown

Date: hh	hh	hhhh MONTH DAY YEAR

62. If <15 years of age and serotype “b” or “unk”, did patient receive Haemophilus influenzae b vaccine?h	Yes h	No h	Unknown

Dose

Date Given

Vaccine Name/Manufacturer Lot Number MONTH DAY YEAR

1 hh	hh	hhhh

2 hh	hh	hhhh

3 hh	hh	hhhh

4 hh	hh	hhhh

_______________________________________________________ ___________________________

_______________________________________________________ ___________________________

_______________________________________________________ ___________________________

_______________________________________________________ ___________________________

Epidemiologic

63. Does this patient: (CHECK ALL THAT APPLY)

Attend a day care* facility h	 	 	 Yes h No h Unknown Facility name _

*DAY CARE IS DEFINED AS A SUPERVISED GROUP OF 2 OR MORE UNRELATED CHILDREN FOR >4 HOURS PER WEEK.

_________________________________________________

Reside in a long term care facility? h Yes h	No h	Unknown Facility name __________________________________________

64. Is this case part of an outbreak? h Yes h No h	Unknown Outbreak name ___________________________________________

Where was this disease acquired?

Imported Country: 

 _______________________________________________________________________________________

 ________________________________________ Imported City: ______________________________________________

Imported State: __________________________________________ Imported County: ___________________________________________

CONFIRMATION METHOD

65. Case status: 

h	 h 

Probable

Suspect

ot a case

h h 

h

66. Does this patient have recurrent disease with the same pathogen?

hhhhhh

h	Yes h	

If yes, previous (1st) state I.D.

 h	

h

67

h

h

No Unknown

. CRF Status: 

h

h

General Comments: _____________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________