Department of Health and Human Services Form 56.37

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Department of Health and Human Services Form 56.37 Powered By Docstoc
					PLAGUE CASE INVESTIGATION REPORT

Patient's Name: Address:

First Name:
Detach before sending to CDC
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Disease Control and Prevention (CDC) P.O. Box 2087 Ft. Collins, CO 80522-2087
Mo. Day Year

Phone No.: ( City:

)

Retrieve Data Reset Form
Form Approved OMB No. 0920-0004

Date of Report: State: County:

PLAGUE CASE INVESTIGATION REPORT
– PATIENT DEMOGRAPHICS –
Zip:

Date Hospitalized
Mo. Day Year

Age:

Sex:

Patient Ethnicity: (select one)

Patient Race: (select all that apply)

■ Male ■ Female ■ Unspecified
Person making call:

■ Hispanic or Latino ■ Unk ■ Not Hispanic or Latino

■ American Indian or ■ Black or African American ■ White ■ Unk Alaska Native Native Hawaiian ■ or Pacific Islander ■ Other ■ Asian
Person taking call:

Agency:

Agency:

Phone No.:

Phone No.:

(

)
If yes, give name and address of person contacted:

(

)

Has local health department been notified?

■ Yes
Physician(s):

■ No
Phone(s):

( (
City: Hospital: Phone(s):

) )

(

)

– ILLNESS –
Date of onset of illness:
Mo. Day Year

Symptoms:

SIGNS: Temperature: __________ R _________ BP __________ P __________ Date: Tender:

Mo.

Day

Year

Bubo:

■ Inguinal ■ Femoral ■ Cervical ■ Axillary
Location:

■ Other __ __ ■ R __ __ ■ L

Size (cm) describe:

Erythema:

■ Yes ■ No
Insect Bite(s): Location:

■ Yes ■ No

Skin Ulcer:

■ Yes ■ No
Cough:

■ Yes ■ No
Date of onset of cough:
Mo. Day Year

■ Yes ■ No
Current condition and prognosis:

Cough productive:

■ Yes ■ No

OUTCOME:

Mo.

Day

Year

■ Survived ■ Died

Discharge Date:

Autopsy:

■ Yes ■ No

Public reporting burden of this collection of information is estimated to average 15 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, Project Clearance Officer, 1600 Clifton Road, MS E-71, Atlanta, GA 30333, ATTN: PRA (0920-0004). Do not send the completed form to this address.

CDC 56.37 Rev. 05-2004

PLAGUE CASE INVESTIGATION REPORT

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Personal Identifiers are not Transmitted to CDC

– LABORATORY –
Chest X-ray: Pneumonia: Date :
Mo. Day Year

■ Yes ■ No
WBC Count:

■ Unknown
Left Shift:

■ Yes ■ No ■ Yes
Mono:

■ Unknown
Bands: Polys:

___________________
Lymph:

■ No
Eos:

___________________

___________________
Bas:

___________________
Bacteria on blood smear?

___________________

___________________

___________________

■ Yes ■ No ■ Yes ■ No
Bubo Aspirate:

■ Don’t know

_________________________________________________________________________________

Blood cultures taken?

How many? ________

Results? ________________________________________________________________
POS. NEG.

Sputum:

■ Yes ■ No
Date:
Mo. Day Year

Gram Stain . . . . . . . . . . . Wayson Strain FA (Plague) Culture
.......

(or Wright’s, Giemsa)
..........

■ ■ ■ ■ ■ ■ ■ ■

POS.

NEG.

■ Yes ■ No
Date:
Mo. Day Year

Gram Stain . . . . . . . . . . . Wayson Strain FA (Plague) Culture
Mo.

.......

(or Wright’s, Giemsa)
..........

■ ■ ■ ■ ■ ■ ■ ■
Year

...............

...............
Day

Serologies: S1 result: __________________________________________________________ S2 result: __________________________________________________________

Date Serum Drawn: Date Serum Drawn:

– ANTIBIOTICS –
Treatment 1. _______________________________________ 2. _______________________________________ 3. _______________________________________ Isolation: Date Started
Mo. Day

Date Stopped
Mo. Day

Dosage & Schedule 1. _______________________________________ 2. _______________________________________ 3. _______________________________________

■ Respiratory

■ Wound precautions only

■ None

– EPIDEMIOLOGY –
Whereabouts during 10 days before onset on (dates) (Include all outdoor activities)

Other persons ill after same exposure? (Names and whereabouts):

Did patient handle sick or dead rodents, rabbits, or other animals? Patient recall flea or other insect bites?

■ Yes ■ No

If so, where? ____________________________________________________

■ Yes ■ No

Wild animal contact, including hunting?

■ Yes ■ No

Contact with human plague patient?

■ Yes ■ No

Contacts or relatives who died in past week?

■ Yes ■ No

Pets (kind and number)

Illness in pets?

_______________________________________________
CDC 56.37 Rev. 05-2004

■ Yes ■ No

Pets free roaming?

Describe: ___________________________________
PLAGUE CASE INVESTIGATION REPORT

■ Yes ■ No ■ Don’t know
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– EPIDEMIOLOGY (Continued) – (Community Contacts During Illness) NAME* (a) Family and Household (Setting and Circumstances) LOCATION and TIME DATE
(mm, dd, yyyy)

__ __/ __ __/ __ __ __ __ __ __/ __ __/ __ __ __ __ __ __/ __ __/ __ __ __ __ __ __/ __ __/ __ __ __ __ __ __/ __ __/ __ __ __ __ (b) Work or School __ __/ __ __/ __ __ __ __ __ __/ __ __/ __ __ __ __ __ __/ __ __/ __ __ __ __ __ __/ __ __/ __ __ __ __ __ __/ __ __/ __ __ __ __ (c) Friends/acquaintances __ __/ __ __/ __ __ __ __ __ __/ __ __/ __ __ __ __ __ __/ __ __/ __ __ __ __ __ __/ __ __/ __ __ __ __ __ __/ __ __/ __ __ __ __ (d) Hospital __ __/ __ __/ __ __ __ __ __ __/ __ __/ __ __ __ __ __ __/ __ __/ __ __ __ __ __ __/ __ __/ __ __ __ __
*When a group too large to list is involved, the location, setting, time, and date will allow relevant persons to be traced (e.g., church, school, social activities, etc.) To carry out field investigation in the home or work area, it would be helpful to get permission to enter and work on private property. Who should be contacted for such permission? Name: Phone No.:

(
(Area Code)

)

CDC 56.37 Rev. 05-2004

PLAGUE CASE INVESTIGATION REPORT

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Description: Department of Health and Human Services Form