METHODS OF SUBMISSION • Attach form to MEDSIS case • Email it with security to [email protected] (include

[secure] in the subject line) Chikungunya Case Investigation Form • Fax it to 602-364-3198

Investigator: ______Date of interview: ______

Patient Information Name ______Gender Female Male Unknown Date of Birth ______Address ______Phone/Cell# ______Email ______Guardian(s) ______Occupation/School ______Living Situation Correctional facility Crisis center Homeless Hospital Long-term care Military base Multi-family dwelling Residential rehabilitation/Halfway house Residential school Single-family housing Unknown Race Alaskan Indian or Native American Asian Black Hawaiian or Pacific Islander White Unknown Other: ______Ethnicity Hispanic or Latino Not Hispanic or Latino Unknown Tribal Affiliation Ak-Chin Cocopah Colorado River Fort McDowell Fort Mohave Fort Yuma Quechan Gila River Havasupai Hopi Hualapai Kaibab-Paiute Navajo Nation Pasqua Yaqui Salt River Pima-Maricopa San Carlos Apache San Juan Southern Paiute Tohono O’odham Tonto Apache White Mountain Yavapai Apache Yavapai Prescott Zuni Out of State Unk Primary Language ______Can interview in English? Yes No Died Yes Date of death: ______No

Case Information MEDSIS Case # ______County: ______Initial report date ______Classification Confirmed Not a case Probable Suspect Reporter ______Reporter Organization ______Reporter phone # ______Email ______Provider ______Provider Organization ______Provider phone # ______Email ______Onset date ______Diagnosis date ______

Education & Control Actions Education provided? Yes Offered but declined Not offered N/A Date education provided ______Type of education Verbal Written Web-based Other ______Control actions taken Yes No Unknown

Symptoms & Outcomes Clinical Picture Unknown Asymptomatic Encephalitis- including Meningoencephalitis Meningitis Other neuroinvasive Other clinical Uncomplicated fever Symptoms (check all that apply, circle primary symptoms) Headache Joint pain Muscle pain Rash Nausea/vomiting/diarrhea Extreme fatigue Joint swelling Muscle weakness Fever (>38° c or 100°F) Max temp ______Other (specify) ______Is the patient hospitalized? Yes Admit date: ______No Unk Is the patient breastfeeding a child? Yes No Unk Is the patient a breastfed child? Yes No Unk

Medical History Vaccination History Cancer Viral Hepatitis Hypertension Heart disease Yellow fever Date ______Pulmonary disease Immunosuppressive condition Japanese encephalitis Date ______Diabetes Type: ______Tick-borne encephalitis Date ______Mosquito-borne illness (Dengue, Yellow Fever, Japanese Encephalitis, West Nile virus, St. Louis encephalitis, or Flavivirus) Other medical history (chronic/infectious) ______

Risk Factor Assessment Within 14 days of onset of symptoms, did the patient have known mosquito exposure? Yes Dates: ______Locations:______No Unk

Within 14 days of onset of Travel dates/locations: Within 14 days of onset of symptoms, did the patient symptoms, did the patient travel? Date from: ______donate an organ or tissue? (mark furthest destination point if there Date to: ______Yes No Unk was more than one travel destination) Location: ______Date: ______Yes, outside of US

Yes, outside of Arizona Within 14 days of onset of Yes, outside county of residence Date from: ______symptoms, did the patient No travel history Date to: ______donate blood? Unknown Location: ______Yes No Unk

In the 30 days prior to onset of symptoms, did the patient receive blood or blood product? Yes No Unk In the 30 days prior to onset of symptoms, did the patient receive an organ or tissue transplant? Yes No Unk

Acquired? In utero In a laboratory Occupationally (non-lab) Length of illness (days) ______Discharge date, if hospitalized ______Outcome: Died Full recovery Recovery with sequelae, describe: ______Treatment description: ______

Notes:

Revised 4/27/17