Data Collection Forms

These forms are designed to assist investigators in collecting information relevant to identifying etiologies of respiratory outbreaks. They are not for reporting an outbreak of disease to CDC. For reporting assistance, please refer to your state health department.

Long Form

The Data Collection—Long Form [13 pages] was developed to provide a comprehensive set of questions to consider using when developing a case questionnaire for investigation of outbreaks of unknown respiratory illness. These questions cover a range of topic areas including

• Patient and family contact information
• Occupation
• Travel history and other exposures of interest
• Extensive past medical history review
• A comprehensive list of potential laboratory tests completed

It would be unusual to use the form in its entirety for any particular outbreak; pieces of the form should be used as necessary based on factors surrounding the outbreak, including the differential diagnoses and the population affected.

In contrast to the short case questionnaire form, information needed to answer many of the questions on this form may not be available, and data collection may require compiling information from various sources, including medical records; physician, patient, and family interviews; and public health partners.

Short Form

The Data Collection—Short Form [2 pages] is a template that is ready to use for quick data collection for ill persons (or “case patients”) that are part of unexplained respiratory outbreak field investigations. The form is not intended to be comprehensive; rather, it should be modified as necessary to accommodate the particular data requirements of the current outbreak investigation. It is meant to collect important common or “core” data elements needed in most respiratory disease outbreak investigations.

The first page of the form allows for collection of basic demographic, symptom, and exposure information from a patient interview. The second page collects objective clinical and laboratory testing information and is to be completed by an interview with the treating or reporting physician or a review of the ill person’s medical record.