– LEGIONELLOSIS ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –
Patient’s Name:
Phone No.: (
Patient
Chart No.:
(Last, First, MI.)
Address:
(Number, Street, Apt. No.)
(City, State)
)
Hospital:
(Zip Code)
er information is not transmitted to CDC –
2015 Legionellosis Active Bacterial Core
Surveillance (ABCs) Case Report Form
DEPARTMENT OF
HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
ATLANTA, GA 30333
A CORE COMPONENT OF THE EMERGING INFECTIONS PROGRAM NETWORK
– SHADED AREAS FOR OFFICE USE ONLY –
2. COUNTY:
(Residence of Patient)
1. STATE:
(Residence of Patient)
5. STATE HEALTH DEPT. CASE NO.
(From CDC Legionellosis
case report form for passive
surveillance):
6. DATE OF SYMPTOM ONSET
OF LEGIONELLOSIS: (note this is
NOT date of admission)
Day
Yes
No
Unknown
1
2
9
7a. WAS PATIENT
HOSPITALIZED?
1
Yes
2
Mo.
If yes,
Date of
admission:
Day
Private residence
1
Homeless
1
Acute care hospital
1
Long term care facility
1
Incarcerated
1
Other (specify) _________________
1
Long term acute care facility 1
Assisted Living
1
Unknown
Day
12a. AGE:
(at time
of onset)
Year
13. SEX:
12b. Is age in day/mo/yr?
1
15a. WEIGHT:
______lbs______ oz OR ______ kg
Days 2
Mos. 3
OR
Unknown
15b. HEIGHT:
______ft ______ in OR ______ cm OR
Unknown
15c. BMI:
___ ___.___ OR
17. OUTCOME:
1
Died 9
Unknown
1
CT 2
X-ray 3
Both 4
Neither 9
Male
1
Hispanic or Latino
2
Female
2
Not Hispanic or Latino
9
Unknown
Yrs.
1
Asian
Black
1
1
American Indian
or Alaska Native 1
Native Hawaiian
or Other Pacific Islander
Medicaid/state assistance program 1
1
Unknown
1
Incarcerated
Unknown
Other (specify) __________________
18. If patient died, was the initial culture or first positive test obtained from autopsy? 1
1
Cavitation
1
Cannot rule out pneumonia
Empyema
1
No evidence of pneumonia
Pneumonitis
1
Report not available
Multiple lobar infiltrate (unilateral) 1
Pulmonary edema
1
Multiple lobar infiltrate (bilateral) 1
Interstitial infiltrate
1
482.84/A48.1 (Legionnaires’ disease)
482 (Other bacterial pneumonia)
482.3 (Pneumonia due to other specified bacteria)
482.83/J15.6 (Other gram-negative bacteria)
482.89/J15.8 (Pneumonia due to other specified bacteria)
1
1
1
1
1
2
No 9
Unknown
Yes 2
No* 9
Unknown*
*If no or unknown, choose syndrome or infection type:
Other (specify)
_____________________________________
22. Discharge diagnosis (check all that apply):
Yes
20. WAS THE PATIENT DIAGNOSED WITH PNEUMONIA?:
Unknown
1
CDC 52.15C REV. 01-2015
White
1
1
Lobar (NOT interstitial) infiltrate
No
1
Uninsured
1
Yes 2
Unknown
Indian Health Service (IHS) 1
ARDS (acute respiratory distress syndrome)
Unknown
9
Military
1
1
No
1
Atelectasis
9
Yes 2
1
Air space/alveolar density/opacity/disease1
1
1
1
1
1
1
Medicare
1
21. Did this patient have
a positive flu test
10 days prior to or
following a positive
Legionellatest or
positiveLegionella
culture?
8b. If YES,
hospital I.D.:
Year
Private
1
1
Day
Unknown
1
Consolidation
1
9
1
Pneumonia/bronchopneumonia
1
No
14b. RACE: (Check all that apply)
1
1
Single lobar
Year
10a. Was patient transferred 10b. If YES, hospital I.D.:
from another hospital?
14a. ETHNIC ORIGIN:
1
1
2
Mo.
If yes, check all that apply from the radiology report:
For pneumonia/consolidation/infiltrate
Yes
Year
19. DID THE PATIENT HAVE A CHEST CT OR CHEST X-RAY WITHIN 72 HOURS OF ADMISSION?:
1
Day
16. TYPE OF INSURANCE: (Check all that apply)
Unknown
Survived 2
Mo.
No
9b. If resident of a facility,
what was the name of
the facility?
1
Mo.
Date of discharge:
Year
Date
of discharge:
9a. Where was the patient a resident in the 10 days prior to illness onset?
(Check all that apply)
11. DATE OF BIRTH:
Day
8a. Excluding the current hospitalization, was the
patient hospitalized at any time in the 10 days
prior to illness onset?
Yes
No
Unknown
4b. HOSPITAL I.D. WHERE
PATIENT TREATED:
If YES, date of admission:
Mo.
Year
7b. If patient was hospitalized,
7c. Did the patient require
was this patient admitted to
mechanical ventilation?
the ICU during hospitalization?
1
2
9
4a. HOSPITAL/LAB I.D. WHERE FIRST
CULTURE IDENTIFIED OR FIRST
POSITIVE TEST:
3. STATE I.D.:
Mo.
OMB No. 0920-0978
1
8
9
Pontiac fever (fever and myalgia without pneumonia)
Extrapulmonary infection (specify):
__________________________________________
Unknown
1
482.9/J15.9 (Bacterial pneumonia unspecified)
483 (Pneumonia due to other specified organism)
1
483.8/J16.8 (Pneumonia due to other specified organism)
484 (Pneumonia in infectious diseases classified elsewhere) 1
484.8/J17 (Pneumonia in infectious diseases classified elsewhere)1
485/J18.0 (Bronchopneumonia
organism unspecified)
486/J18.9 (Pneumonia, organism
unspecified)
None of these listed
No ICD codes in chart
Public reporting burden of this collection of information is estimated to average 10 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 conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to CDC, CDC/ATSDR Reports Clearance O cer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0978).
Do not send the completed form to this address.
– LEGIONELLOSIS ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –
– IMPORTANT – PLEASE COMPLETE THE BACK OF THIS FORM –
Page 1 of 2
23. UNDERLYING CAUSES OR PRIOR ILLNESSES:
1
1
1
1
1
1
1
1
1
1
1
1
(Check all that apply OR if NONE or CHART UNAVAILABLE, check appropriate box)1
AIDS or CD4 count <200
Alcohol Abuse, Current
Alcohol Abuse, Past
Asthma
Atherosclerotic Cardiovascular Disease (ASCVD)/CAD
Bone Marrow Transplant (BMT)
Cerebral Vascular Accident (CVA)/Stroke
Chronic Kidney Disease
Current Chronic Dialysis
Cirrhosis/Liver Failure
Complement Deficiency
Dementia
1
1
1
1
1
1
1
1
Legionella Test
Date Collected
24. Urine Antigen, EIA
25. Culture
26. Paired Serology, IFA
or ELISA
27. PCR
(direct specimen only)
28. DFA
(direct fluorescence
assay, direct
specimen only)
29. IHC
(immunohistochemistry)
Was this test ordered?
1
2
9
1
2
9
Yes
No
Unknown
Yes
No
Unknown
Diabetes Mellitus
Dysphagia
Emphysema/COPD
Heart Failure/CHF
HIV Infection
Hodgkin’s Disease/Lymphoma
Immunoglobulin Deficiency
Immunosuppressive Therapy
(Steroids, Chemotherapy, Radiation)
IVDU, Current
IVDU, Past
1
1
/
/
/
Acute
Convalescent
1 Yes
2 No
9 Unknown
Convalescent
1
2
9
1
2
9
1
2
9
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
/
/
/
/
Leukemia
Multiple Myeloma
Multiple Sclerosis
Nephrotic Syndrome
Neuromuscular Disorder
Obesity
Other Drug Use, Current
Other Drug Use, Past
Parkinson’s Disease
Peripheral Neuropathy
Plegias/Paralysis
Site
Unknown
1
Premature Birth (specify gestational
age at birth)
(wks)
Seizure/Seizure Disorder
Sickle Cell Anemia
Smoker, Current
Smoker, Former
Solid Organ Malignancy
Solid Organ Transplant
Splenectomy/Asplenia
Systemic Lupus Erythematosus (SLE)
Other (specify) __________________
1
1
1
1
1
1
1
1
1
Result
/
Acute
1 Yes
2 No
9 Unknown
/
1
1
1
1
1
1
1
1
1
1
1
None 1
1 Sputum
2 BAL/bronchial washing
3 Lung tissue
4 Pleural fluid
5 Blood
8 Other (specify)
________________________
Species
1
2
9
Positive
Negative
Unknown or Indeterminate
1
2
9
L. pneumophila
If yes, list serogroup:
1 serogroup 1
8 Other (specify) _________________
Positive
9 Unknown
Negative
Unknown or Indeterminate 2 L. species (non-pneumophila)
8 L. species, other
(specify)____________________
9 L. species, unknown or not specified
1
Acute
Acute
Species: _____________________________
1 Positive
If yes, titer: ____________
2 Negative
Serogroup(s): ________________________
9 Unknown or Indeterminate
/
Convalescent
Convalescent
Species: _____________________________
1 Positive
If yes, titer: ____________
2 Negative
Serogroup(s): ________________________
9 Unknown or Indeterminate
/
/
1 Sputum
2 BAL/bronchial washing
3 Lung tissue
4 Pleural fluid
5 Blood
8 Other (specify)
________________________
/
1 Sputum
2 BAL/bronchial washing
3 Lung tissue
4 Pleural fluid
5 Blood
8 Other (specify)
________________________
/
1 Sputum
2 BAL/bronchial washing
3 Lung tissue
4 Pleural fluid
5 Blood
8 Other (specify)
________________________
L. pneumophila
L. species (non-pneumophila)
L. species, other
(specify)____________________
L. species, unknown or not specified
1
2
9
1
2
Positive
8
Negative
Unknown or Indeterminate
9
1
2
9
L. pneumophila
If yes, list serogroup:
1 serogroup 1
8 Other (specify) _________________
Positive
9 Unknown
Negative
Unknown or Indeterminate 2 L. species (non-pneumophila)
8 L. species, other
(specify)____________________
9 L. species, unknown or not specified
1
2
9
L. pneumophila
If yes, list serogroup:
1 serogroup 1
8 Other (specify) _________________
Positive
9 Unknown
Negative
Unknown or Indeterminate 2 L. species (non-pneumophila)
8 L. species, other
(specify)____________________
9 L. species, unknown or not specified
1
1
30. COMMENTS:
– SURVEILLANCE OFFICE USE ONLY –
32. Was this case also identified
33. CRF Status:
34. Does this case have
31. Was case first
recurrent disease?
identified through through routine passive notifiable
Complete
1
disease surveillance?
audit?
2
Incomplete
1
Yes 2
No 9
Unknown
1 Yes 2
No 1
Yes 2
No 9
Unknown
3
Edited & Correct
If yes, previous (1st) state ID:
4
Chart unavailable
9 Unknown
after 3 requests
35. Case status:
1
Confirmed
2
Mo.
Day
37. Initials of
S.O.:
Suspect
Year
Submitted By:
Phone No. : (
)
Physician’s Name:
Phone No. : (
)
CDC 52.15C REV. 01-2015
36. Date reported to EIP site:
– LEGIONELLOSIS ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –
Date:
/
/
Page 2 of 2