Clinical Data Collection Forms and Templates for Collection of Information on Patients Infected with Novel Influenza A (H1N1)

May 12, 2009 3:00 PM ET

This page is designed to give clinicians access to the latest guidelines and information on the evolving novel H1N1 influenza investigation.

CDC Clinical Data Collection Forms and Templates for Collection of Information on Patients Infected with Novel Influenza A (H1N1)

The following novel Influenza A (H1N1) data collection forms are being made available for use by public health officials, and for researchers and clinicians in the medical and academic communities both in the United States and in other countries.   These templates represent a variety of data collection instruments that can be used to collect information on persons with novel Influenza A H1N1 infection.  The data obtained from these instruments can help characterize the disease spectrum and severity, and help to understand what factors may increase the risk for more severe disease, and may guide healthcare decisions and resource allocation. 

This website will be updated as new forms become available.

H1N1 Influenza Case Report Form, v3.050109

PDF Format (PDF), Word Format (Word)

This form asked for limited information on cases and is a subset of the information requested in the “Novel Influenza Case Investigation Form” below.  US state health departments have been asked to complete this form for individual cases and send the information to the CDC.

Addendums:

• Influenza Healthcare Worker Case Report Addendum, version 3

  PDF Format (PDF), Word Format (Word)
  

  This form can be used to collect supplementary information on cases healthcare worker cases.  This provides added information from what is contained in the H1N1 Influenza Case Report Form, v3.050109 - (PDF) (Word)

• Influenza Case Report: Addendum for Pregnant Women  

  PDF Format (PDF), Word Format (Word)
  

  This form can be used to collect supplementary information on cases among pregnant women.  This provides added information from what is contained in the H1N1 Influenza Case Report Form, v3.050109 - (PDF) (Word)

Novel Influenza Case Investigation Form, v 050209  

PDF Format (PDF), Word Format (Word)
This form provides for the collection of more detailed information on cases on all cases.

Influenza Investigation, Contact Tracing, v 050209

PDF Format (PDF), Word Format (Word)
This form provides for the collection of detailed information on persons who are contacts of ill persons and also collects information that can be used to assess the type and intensity of a persons exposure to an ill person.

Novel Influenza A: Clinical Description of Hospitalized Cases, version 28 April 2009

PDF Format (PDF), Word Format (Word)
This form was approved by CDC Institutional Review Board (IRB) (the CDC ethics review board) with IRB approval that expires 24 April 2010. This form provides for the collection of detailed clinical data on persons who are hospitalized cases with novel influenza A (H1N1) infection.

Addendums:

• Influenza Case Report: Addendum for Pregnant Woman

  PDF Format (PDF), Word Format (Word)

  This form supplements the “Novel Influenza A: Clinical Description of Hospitalized Cases, version 28 April 2009” form (PDF) (Word), and collects additional detailed information from cases among pregnant women who are hospitalized with novel influenza A (H1N1) infection.