Free Influenza Surveillance 09292006 - Indiana

INFLUENZA LAB SUBMISSION - Page 1 of 3
14783

Indiana State Department of Health
State Form 52419 (R2 / 7-07)

Instructions: Please readInstructions: Please read before completing this form before yopu complete this form

1 Fill in circles like this:
Not like this: Mark mistakes like this:

2 Print capital letters only
and numbers completely inside boxes:

ABC3

3 Please complete
all items on form.

Section 1. Demographic Information

Last Name

Authorization Code

First Name

MI

Phone Number

-

-

Number & Street Address

City

State

ZIP Code

/
County

/
Age Not Hispanic or Latino Unknown

Date of Birth (mm/dd/yyyy) White Other/Multiracial Unknown

Race:
Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander

Ethnicity:
Hispanic or Latino

Is Age in day/mo/yr?
Days Months Years

Sex:
Male Female Unknown

Occupation Institution Resident ? No Yes Institution Type Prison Nursing Home Other (specify)

-

Phone # of Employer/School/Care Facility/Institution

Name of

Employer

School

Care Facility

Institution

Address of Employer/School/Care Facility/Institution

City State ZIP Code

Section 2. Clinical Information
Specimen Information: Use a separate form for each Specimen Nasopharyngeal Swab Isolate(type) / /

/
Is Patient Immunocompromised?

/
Yes No

Date of Collection (mm/dd/yyyy)

Date of Illness Onset (mm/dd/yyyy)

Clinical Diagnosis Positive Rapid Test Type A Initial Typing

Negative Type B

Not Performed Type A/B Vaccine Type Killed Vaccine 1

/
2

/

Vaccination Date (mm/dd/yyyy)

/

/

Date of Rapid Test (mm/dd/yyyy) Attenuated Vaccine/Flu Mist

Number of Doses

For ISDH Lab. Use ONLY

Date Received (mm/dd/yyyy)

/

/

Place Label here

14783

INFLUENZA LAB SUBMISSION - Page 2 of 3
14783
State Form 52419 (R2 / 7-07)

Section 2. Clinical Information (continued)

Doctor/Clinic Name

Establishment Name Number & Street Address

City ZIP Code Phone Number

-

Yes

Fax Number

/

/

Sentinel #

E-Mail Address Patient Received/Receiving Antivirals? No

If Yes, Date Administered (mm/dd/yyyy)

Antiviral Administered State of Illness Symptomatic Asymptomatic

(If patient is symptomatic, please check all signs/symptoms that apply)
Respiratory Common Cold Acute Resp. Dis. Bronchitis Pneumonitis Pharyngitis Upper Resp. Inf. Gastrointestinal Nausea Vomiting Diarrhea Gastroenteritis Cardiovascular Myocarditis Pericarditis Endocarditis Cardiomegaly

General Symptoms Fever Headache Sore Throat Cough Myalgia

CNS Encephalitis Meningitis Ocular Conjunctivitis Chorioretinitis Blurred Vision

Exanthema Maculopapular Papular Hemorrhagic Vesicular Petechial

.
Fever Temp (degrees F)

Other Symptoms (please specify)

Section 3. Risk Factors

Recently Traveled to/from

/
Birds Animals

/
Family Community

/

/

Date of Departure (mm/dd/yyyy) Patient Contact with (check all that apply) :

Date of Return (mm/dd/yyyy)

Resp. Disease Outbreak

14783

INFLUENZA LAB SUBMISSION ­ Page 3 of 3
State Form 52419 (R2 / 7-07)

The purpose of this program is to conduct enhanced surveillance for influenza and other respiratory viruses in the State of Indiana. Patients presenting with an influenza-like illness, defined as: fever greater than 100o and either cough or sore throat, should be selected for laboratory testing at the ISDH each week. The nasopharyngeal swabs collected for isolation should be collected within 72 hours of onset of symptoms. You do not need to collect from every patient. Use your professional judgment to collect up to 4 specimens each day, Monday through Thursday, to send to the ISDH Labs. STORAGE AND STABILITY: 1) Immediately upon viral isolation kit receipt, remove and freeze the refrigerant pack. 2) Store the cardboard box with the Styrofoam container and all the other components at room temperature until needed. 3) Do not use the transport medium beyond the expiration date. If your transport medium has expired, please discard and contact the ISDH Container Department at 317.921.5500 or e-mail ([email protected]) to request a new lot number. SPECIMEN COLLECTION: 1) The nasopharynx is the collection site of choice. Use the small swab on the stainless steel shaft for collecting the nasopharyngeal specimen. 2) Using aseptic technique, peel back the swab package and remove the swab. 3) Take a vigorous sample and place the swab in a tube of transport medium. Break off the shaft at the score and secure the lid tightly. 4) Label each tube with the patient's name and the collection date. 5) Complete an Influenza Lab Submission form for each specimen. Make sure the clinic address is complete. 6) Under refrigeration, promptly send to the laboratory for immediate processing. Remember to send specimens Monday through Thursday only. 7) Refrigerate the specimens if storing overnight. Holding the specimens longer than 24 hours will decrease the chance for influenza isolation. TRANSPORTATION: 1) Wrap the specimen(s) in an absorbent pad and secure all specimens in the Ziplock-type bag. 2) Place the completed Influenza Lab Submission form(s) in the liner of the bag and enclose with the frozen pack in the Styrofoam container. Secure the box with packaging tape. 3) Complete the sender information on the FedEx Air Bill and affix the air bill to the box and call FedEx for pickup. ISDH Contacts: Laboratory: Phone 317.921.5500 - Fax 317.927.7804 Epidemiology: Shawn Richards 317.233.7740 - Fax 317.234.2812

Indiana State Department of Health Laboratories (Virology) 550 W. 16th Street, Suite B Indianapolis, IN 46202