LEGIONELLOSIS INVESTIGATION FORM
BASIC DEMOGRAPHIC DATA
Last Name:______First Name:______Middle Name:______
DOB: __ __ / __ __ /______Age: ______years months Current Sex: Female Male Unknown
Is the patient deceased? No Unknown Yes Date of Death: __ __ / __ __ /______
Street Address 1:______Street Address 2:______
City:______State:______Zip Code:______County:______
Home Phone: (______) ‐ ______‐ ______Cell Phone: (______) ‐ ______‐ ______Work Phone: (______) ‐ ______‐ ______Ext. ______
Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown
Race: American Indian/Alaska Native Asian Black/African American Native Hawaiian/Other Pacific Islander White Unknown
INVESTIGATION SUMMARY
Investigation Start Date: __ __ / __ __ /______Investigation Status: Open Closed Investigator:______
REPORTING SOURCE
Date of Report: __ __ / __ __ /______Reporting Source:______
CLINICAL
Physician’s Name:______Phone Number: (______) ‐ ______‐ ______Ext. ______
Was patient hospitalized for this illness? No Unknown Yes If yes: Hospital Name:______
Admission Date: __ __ / __ __ /______Discharge Date: __ __ / __ __ /______Duration of Stay ______day(s)
Diagnosis Date: __ __ / __ __ /______Illness Onset Date: __ __ / __ __ /______Illness End Date: __ __ / __ __ /______
Age at Onset: ______days hours minutes months unknown weeks years
Did the patient die from this illness? No Unknown Yes Date of Death: __ __ / __ __ /______EPIDEMIOLOGIC
Is this patient associated with a day care facility? No Unknown Yes Is this patient a food handler? No Unknown Yes
Is this case part of an outbreak? No Unknown Yes If yes, outbreak name:______
Case Status: Confirmed Not a Case Probable Suspect Unknown MMWR Week: ______MMWR Year:______
ADMINISTRATIVE
General Comments:______
______
______
PHA4 SUPERVISOR REVIEW
Date Due: __ __ / __ __ /______Investigation ready for supervisor review: Reviewed (Complete) Reviewed (Incomplete)
Date investigation ready for supervisor review: __ __ / __ __ /______Reviewed (Not a case) Yes
Review comments (completed by supervisor):______
ADPH Legionellosis InvFm (Rev. 02/2013 MLS) 1/3 SOURCES OF EXPOSURE (in the two weeks before onset, did patient)
Travel or stay overnight somewhere other than usual residence: No Unknown Yes If yes, what was the purpose of travel? Business Migration (immigration to US) Tourism Visiting relatives/friends Other ______Please specify the destination(s):
Destination 1 Type: Domestic State/Territory: ______International Country: ______
Mode of Travel: Airplane Bus Car Cruise ship Train Arrival Date: __ __ / __ __ /______Departure Date: __ __ / __ __ /______
Destination 2 Type: Domestic State/Territory: ______International Country: ______
Mode of Travel: Airplane Bus Car Cruise ship Train Arrival Date: __ __ / __ __ /______Departure Date: __ __ / __ __ /______
Destination 3 Type: Domestic State/Territory: ______International Country: ______
Mode of Travel: Airplane Bus Car Cruise ship Train Arrival Date: __ __ / __ __ /______Departure Date: __ __ / __ __ /______
If more than 3 destinations, specify details here: ______
Have dental work? No Unknown Yes If yes, name of dental office and address: ______Visit a hospital as an outpatient? No Unknown Yes If yes, name of hospital and address (visited): ______Works in a hospital? No Unknown Yes If yes, name of hospital and address (worked in): ______
HOSPITAL RELATED (Nosocomial related)
NOT Nosocomial (No inpatient or outpatient hospital visits in the 10 days prior to onset of symptoms): No Unknown Yes POSSIBLY Nosocomial (Patient hospitalized 2‐9 days before onset of legionella infection): No Unknown Yes DEFINITELY Nosocomial (Patient hospitalized 2‐9 days before onset of legionella infection): No Unknown Yes Other (Specify Nosocomial): No Unknown Yes If yes, name: ______Unknown (Nosocomial): No Unknown Yes
SIGNS AND SYMPTOMS (Clinical and Laboratory Evidence)
Fever: No Unknown Yes Myalgia: No Unknown Yes Cough: No Unknown Yes
Clinical Classification: Diagnosis (check one) Laboratory Classification:
Legionnaires’ Disease (Pneumonia, X‐ray diagnosed) Species: ______
Pontiac Fever (Fever, myalgia without pneumonia) Serogroup: ______
Other (Specify): ______
Unknown UNDERLYING CONDITIONS
Did the patient have any of the following underlying conditions?
CSF leak Hodgkin’s disease IVDU
Alcohol abuse Asthma Atherosclerotic cardiovascular disease (ASCVD)/CAD
Burns Cerebral vascular accident (CVA) stroke Chronic GI illness/diarrhea
Cirrhosis/liver failure Cochlear implant Current smoker
Deaf/profound hearing loss Diabetes mellitus (insulin): No Unk Yes Emphysema/COPD
Gastric surgery (type): ______Heart failure Hematologic disease (type): ______
Immunodeficiency (type): ______Immunoglobulin deficiency Immunosuppressive therapy (steroids, chemotherapy)
Leukemia Multiple myeloma Nephrotic Syndrome
None Organ transplant (organ): ______Other liver disease (type): ______
Other malignancy (type): ______Other prior illness (type): ______Other renal disease (type): ______
Peptic ulcer Renal failure/dialysis Sickle cell anemia
Splenectomy/asplenia Systemic lupus erythematosus (SLE) Unknown
ADPH Legionellosis InvFm (Rev. 02/2013 MLS) 2/3 RELATED CASES
Does the patient know of any similarly ill persons? No Unknown Yes
If yes, did the health department collect contact information about other similarly ill persons and investigate further: No Unknown Yes
Are the other cases related to this one? No, sporadic Unknown Yes, household Yes, not household Yes, outbreak Note: Please enter name and Case ID of epi‐linked case(s) in the ALNBS General Comments section.
CASE CLASSIFICATION
Legionnaires’ Disease: Did the patient have fever, myalgia, cough, and clinical or radiographic pneumonia; OR 1 No Unknown Yes Pontiac Fever (milder illness without pneumonia)?
By culture: isolation of any Legionella organism from respiratory secretions, lung tissue, pleural fluid, or other normally sterile fluid. OR 2 By detection of Legionella pneumophila serogroup 1 antigen in urine using validated reagents. No Unknown Yes OR By seroconversion: fourfold or greater rise in specific serum antibody titer to Legionella pneumophila serogroup 1 using validated reagents.
By seroconversion: fourfold or greater rise in antibody titer to specific species or serogroups of Legionella other than L. pneumophila serogroup 1 (e.g., L. micdadei, L. pneumophila serogroup 6). OR By seroconversion: fourfold or greater rise in antibody titer to multiple species of Legionella using pooled antigen and validated reagents. 3 OR No Unknown Yes By the detection of specific Legionella antigen or staining of the organism in respiratory secretions, lung tissue, or pleural fluid by direct fluorescent antibody (DFA) staining, immunohistochemistry (IHC), or other similar method, using validated reagents. OR By detection of Legionella species by a validated nucleic acid assay.
Travel‐associated: a case that has a history of spending at least one night away from home, either in the same
country of residence or abroad, in the ten days before onset of illness.
Confirmed: 1 & 2 Suspect: 1 & 3
ADPH Legionellosis InvFm (Rev. 02/2013 MLS) 3/3