New Jersey Department of Health

AVIAN INFLUENZA SCREENING INFORMATION

Instructions: Fax completed form to: ____________________	For NJDOH Use Only
Date: ____/____/____

Reviewer: _________________

REPORTING INFORMATION
Reported By:
E-#:
Name:
CDRSS #:
Agency:
PHEL Specimen#:
Contact Number:
PATIENT INFORMATION
Race (check all that apply):
Last Name:	First:
White

Black/African American

Asian

American Indian/Alaska

Native Hawaiian/Pacific Islander

Other/Unknown
Address:
City:	State:
County:	Municipality:
Date of Birth:	/ /	Age:	Gender: Male Female	Ethnicity:

Hispanic or Latino

Not Hispanic or Latino

Unknown
Occupation:
CLINICAL INFORMATION
Was the patient evaluated by a healthcare provider?

Yes No Unknown If Yes, provide the following information:
Provider Name:
Address:	City:	State:
Primary Phone No.:	Secondary Phone No.:
During the course of illness, was patient hospitalized?

Yes No Unknown
If Yes, Name of Hospital:
Was patient in ICU?	Yes No Unknown
Was the patient intubated?	Yes No Unknown
SIGNS AND SYMPTOMS	CLINICAL FINDINGS
YES	NO	UNKNOWN	YES	NO	UNKNOWN
Fever >100.4o F (>38o C)	Radiographically confirmed pneumonia
Onset Date:	/ /
Acute respiratory distress syndrome
Were fever reducing drugs taken prior to temperature reading?

Feverish (temperature not taken)

Cough

Sore throat

Shortness of breath

Conjunctivitis	(ARDS)
Other Illness (please describe):
LABORATORY TESTING
Was Rapid Antigen Test performed for influenza?
Yes No Unknown If Yes, date specimen collected:	/ /
Result: Influenza A Influenza B Influenza (type not specified) Negative Pending
RISK FACTORS
In 10 days prior to symptom onset:
YES	NO	UNKNOWN

Did patient travel to a country with documented animal or human cases of Avian Influenza*?

Did patient have direct contact with domestic poultry (e.g., touching sick or dead chickens or ducks or well appearing ducks)?

Did patient consume uncooked poultry or poultry products?

Did patient have direct contact with surfaces contaminated with poultry feces?

Did patient have close contact (within 3 feet) of a known or suspected human case of H5N1?

*http://www.cdc.gov/flu/avian/outbreaks/current.htm

CDS-25

AUG 12

CDS-25, Avian Influenza Screening Information

CDS-25, avian flu, bird flu, avian, influenza, screening, report, flu, communicable disease, CDS

EWhite

2012-03-19

NJDOH