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Plague Case Report Form

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Plague Case Report Form CONFIDENTIAL Iowa Department of Public Health FOR STATE USE ONLY Plague Agency: Status: Confirmed Probable Suspect Not a case Reviewer initials: Investigator: Phone number: Referred to another state: CASE Last name: Date of Birth: / / Estimated? Age: First and middle name: Gender: Female Male Other Est. delivery Pregnant: Yes No Unk Maiden name: Suffix: date: / / Marital Single Married Separated Address line: status: Divorced Parent with partner Widowed American Indian or Alaskan Native Unknown Zip: City: Race: Black or African American White Hawaiian or Pacific Islander Asian State: County: Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown Phone: ( )- - Type: Long-term care Parent/Guardian resident: Yes No Unknown name: Parent/Guardian Facility name: phone: ( )- - Type: EVENT Onset Diagnosis date: / / date: / / Last name: Survived this illness Died from this illness Event outcome: Died unrelated to this illness Unknown First name: Outbreak ARNP MD Yes No Unknown Provider title: related: DO NP PA Outbreak name: Facility name: Exposure setting: Address line 1: Epi-linked: Yes No Unk To whom: ______________ Address line 2: Location In USA, in reporting state acquired: In USA, outside reporting state Zip code: City: Outside USA Unknown information provider Healthcare State: County: State: Country: Phone : ( )- - Type: LABORATORY FINDINGS Laboratory: Accession #: Collection date: / / Date received: / / Specimen source: Result date: / / Positive Result: Result type: Preliminary Final Test type: Negative Organism: Yersinia pestis Antigen: Laboratory: Accession #: Collection date: / / Date received: / / Specimen source: Result date: / / Negative Result: Result type: Preliminary Final Test type: Positive Organism: Yersinia pestis Antigen: Laboratory: Accession #: Collection date: / / Date received: / / Specimen source: Result date: / / Negative Result: Result type: Preliminary Final Test type: Positive Organism: Yersinia pestis Antigen: Center for Acute Disease Epidemiology Fax: 515-281-5698 Plague Revised Feb-11 1 Confidential PATIENT NAME: ______________________________ Iowa Department of Public Health OCCUPATIONS Interpret ‘occupation’ very loosely and consider every person to have at least one ‘occupation’. Occupation type: Job title: Worked after symptom onset: Yes No Unknown Facility name: Date worked from: / / Address: Date worked to: / / Zip code: Removed from duties: Yes No Unknown City: State: County: Date removed: / / Phone: ( )- - Type: Handle food: Yes No Unknown Work in a health care setting: Yes No Unknown Attend or provide child care: Yes No Unknown Direct patient care duties in Attend school: Yes No Unknown lab or health care setting: Yes No Unknown Work in a lab setting: Yes No Unknown Health care worker type: Occupation type: Job title: Worked after symptom onset: Yes No Unknown Facility name: Date worked from: / / Address: Date worked to: / / Zip code: Removed from duties: Yes No Unknown City: State: County: Date removed: / / Phone: ( )- - Type: Handle food: Yes No Unknown Work in a health care setting: Yes No Unknown Attend or provide child care: Yes No Unknown Direct patient care duties in Attend school: Yes No Unknown lab or health care setting: Yes No Unknown Work in a lab setting: Yes No Unknown Health care worker type: HOSPITALIZATIONS Was the case hospitalized? Yes No Unknown Hospital: Isolated at entry: Yes No Unk Isolation type (entry): Admission date: / / Discharge date: / / Days hospitalized: Currently isolated: Yes No Unk Current isolation type: CLINICAL INFO & DIAGNOSIS Bubonic Yes No Unk Pneumonic Yes No Unk Type: Pharangeal Yes No Unk Septicemic Yes No Unk Fever: Yes No Unk Onset date: / / Highest known fever: Celsius Fahrenheit Onset Productive Onset Yes No Unk Yes No Unk Cough: date: / / cough: date: / / Cervical Left Right Femoral Left Right Bubo: Yes No Unk Bubo: Auxillary Left Right Inguinal Left Right Bubo size: inches cent Tender: Yes No Unk Chest x-ray: Yes No Unk Date: / / Result: TREATMENT Antibiotics prescribed: Yes No Unknown Antibiotic: Antibiotic: Antibiotic: Date Date Date started: / / started: / / started: / / Dose: Dose: Dose: mg mg mg Unit: ml # of Unit: ml # of Unit: ml # of IU days: IU days: IU days: # of times a # of times a # of times a day: Route: day: Route: day: Route: Center for Acute Disease Epidemiology Fax: 515-281-5698 Plague Rev. Feb-11 2 Confidential PATIENT NAME: ______________________________ Iowa Department of Public Health INFECTION TIMELINE EXPOSURE PERIOD COMMUNICABLE PERIOD Enter onset date in dark-line ______________________________________Onset________________________________________ box. Enter dates for start of The incubation period for Plague is typically spread by infected exposure period and start and Plague is 1-7 days. fleas. Plague may be spread person end of communicable period. to person if there is contact with pus from suppurating buboes. RISK FACTORS/TRAVEL Traveled within Iowa? City in Departure Return Yes No Unk Iowa: date: / / date: / / Traveled within U.S.? Departure Return Yes No Unk State: City: date: / / date: / / Traveled outside U.S.? Departure Return Yes No Unk Country: date: / / date: / / Worked with a Case: Yes No Unk From date: / / To date: / / Lived with another Case: Yes No Unk From date: / / To date: / / CONTACTS Number of people living in case’s household: Others in contact or with the same exposures Name DOB Gender Address/Phone / / Male Female Zip code: Phone: - - Symptom Is contact a Relationship to case List symptoms onset date case? Spouse Sexual contact Yes / / Child Family member (non-household) No Sibling Friend/acquaintance Roommate Contact- work/school/etc Parent/ guardian Unknown/Other If this contact is a case create a new event and/or case for this contact. Name DOB Gender Address/Phone / / Male Female Zip code: Phone: - - Symptom Is contact a Relationship to case List symptoms onset date case? Spouse Sexual contact Yes / / Child Family member (non-household) No Sibling Friend/acquaintance Roommate Contact- work/school/etc Parent/ guardian Unknown/Other If this contact is a case create a new event and/or case for this contact. Name DOB Gender Address/Phone / / Male Female Zip code: Phone: - - Symptom Is contact a Relationship to case List symptoms onset date case? Spouse Sexual contact Yes / / Child Family member (non-household) No Sibling Friend/acquaintance Roommate Contact- work/school/etc Parent/ guardian Unknown/Other If this contact is a case create a new event and/or case for this contact. NOTES: Center for Acute Disease Epidemiology Fax: 515-281-5698 Plague Rev. Feb-11 3 .
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