Free MOSQUITO_51382_New - Indiana

MOSQUITOBORNE ENCEPHALITIS CASE INVESTIGATION - Page 1 of 4
Indiana State Department of Health State Form 51382 (R/4-04) DIRECTIONS - PLEASE READ BEFORE YOU BEGIN: 1 Print firmly and neatly. 3 Fill in circles like this: Not like this: Only use pens with blue or 2 black ink. Mark mistakes like this:

4 Print capital letters only and numbers completely inside boxes.

A 2 C 3

5 Please complete all items on form. 6 Date format: MM/DD/YY

Section 1. Demographic Information

Last Name

First Name MI Phone Number Number & Street Address

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City

State

ZIP Code

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County Race:
Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander White Other/Multiracial Unknown

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Age
Not Hispanic or Latino Unknown Unknown

Date of Birth Ethnicity:
Hispanic or Latino

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

Sex:
Male Female

Occupation Name of Employer School Day Care

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Phone of Employer/School/Day Care

Address of Employer/School/Day Care

City State ZIP Code Section 2. Clinical Information Method of Testing Used: Symptoms (check all that apply): Fever (degrees) Headache Dizziness Myalgia Fatigue Paralysis Rash Neck Stiffness Stupor Disorientation Tremors Muscle Weakness Convulsions Other, specify: THIS FORM CONTAINS CONFIDENTIAL INFORMATION PER 410 IAC 1-2.3 Duration of Symptoms in Days PCR

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Date of Onset

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Culture Specimen Results: Positive Negative

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Yes No

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Date First Positive Specimen Collected Acute Flaccid Paralysis?

Specimen Results: CSF Serology See page 2. Positive Negative

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MOSQUITOBORNE ENCEPHALITIS CASE INVESTIGATION - Page 2 of 4
Indiana State Department of Health State Form 51382 (R/4-04) Section 2. Clinical Information (continued) 1. IgM Testing 2. IgG Testing

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Acute Value

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Acute Value

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Acute Specimen Taken

Acute Specimen Taken

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Convalescent Specimen Taken

Convalescent Specimen Taken

Convalescent Value Results: Significant Rise in IgM No Significant Rise in IgM Indeterminate

Convalescent Value Results: Significant Rise in IgG No Significant Rise in IgG Indeterminate

Pending Not Done Unknown

Pending Not Done Unknown

Physician/Hospital that Collected Specimen

Physician/Hospital Address

City State ZIP Code

Physician/Hospital Phone Yes No

If Yes, admission date: Discharge date: Hospital:

Was the patient hospitalized before or during infection?

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Did patient die? Yes Diagnosis: Encephalitis Uncomplicated fever Other clinical

No

Meningitis Asymptomatic infection Unknown Yes Yes Yes Yes Yes Yes No No No No No No
If Yes, donation date

1. Did patient receive blood or blood product within previous 30 days? 2. Did patient donate blood or blood product within previous 30 days? 3. Is the patient a Presumptive Viremic donor? 4. Was patient an organ recipient or donor within previous 30 days? 5. Is patient pregnant? 6. Was the patient breast-feeding at the time of the illness?

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THIS FORM CONTAINS CONFIDENTIAL INFORMATION PER 410 IAC 1-2.3

MOSQUITOBORNE ENCEPHALITIS CASE INVESTIGATION - Page 3 of 4
Indiana State Department of Health State Form 51382 (R/4-04) Section 3. Risk Factors Patient's home setting: Suburban Urban Rural

Is the patient's home located adjacent to (check all that apply): Wetlands Woods Marsh/Bog Dumps Streams Ponds Sewage/Septic Effluent Other Area(s) of Standing Water Are any of the following water containers located outside of the home or area (check all that apply)? Birdbaths Garden Ponds Other Containers, specify: Does home have working screens for windows and doors? Yes No Fountains Pools Used Tires

During the two weeks prior to symptoms, did the patient:
Engage in outdoor activities at home? Yes No

If Yes, describe

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Date Camping

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Hiking Fishing Picnicking

Engage in the following activities (check all that apply)?

If so, where

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Date Yes

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No

Travel to recreational areas within county of residence?

If Yes, where

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Date:

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Travel outside of county of residence but within Indiana? Yes No

If Yes, where

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Date

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Travel outside of Indiana? Yes No

If Yes, where

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Date

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THIS FORM CONTAINS CONFIDENTIAL INFORMATION PER 410 IAC 1-2.3

MOSQUITOBORNE ENCEPHALITIS CASE INVESTIGATION - Page 4 of 4
Indiana State Department of Health State Form 51382 (R/4-04) Section 3. Risk Factors (Continued) Stay overnight away from home? Yes No

If Yes, where

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Date Yes

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No

During the two weeks prior to symptoms, did the patient:
Sustain any known mosquito bites?

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If Yes, date: Diagnosis:

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Section 4. Diagnosis

Eastern Equine Encephalitis St. Louis Encephalitis La Crosse Encephalitis West Nile Encephalitis Other

Suspect Suspect Suspect Suspect Suspect

Probable Probable Probable Probable Probable

Confirmed Confirmed Confirmed Confirmed Confirmed

If Other, specify Section 5. Comments/Follow-up Comments:

Investigator Name

Agency

Phone Number

Date

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THIS FORM CONTAINS CONFIDENTIAL INFORMATION PER 410 IAC 1-2.3