Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS)

Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS)

Date the case was reported to the CDC (MM/DD/YYYY)

State ID Number

Name of Jurisdiction?

Date reported to local health center (MM/DD/YYYY)

Last name of submitter

First name of submitter

State abbreviation

Affiliation of submitter with the victim

Phone number submitter can be reached

E-mail submitter can be reached

Patient ID number

Patient's city of Residence

Patient's county of Residence

Patient's state of Residence - abbreviation

Age of Patient

Sex of patient (M - Males or F - Female)

Ethnicity of patient

Nationality of patient

Type of residency of the patient

Race of patient

Date symptoms began (MM/DD/YYYY)

Fever in degrees F

Date fever began (MM/DD/YYYY)

Fever above 100.4 F ? (Enter 'Y' for Yes, and 'N' for No)

Lower respiratory symptoms? (Enter 'Y' for Yes, and 'N' for No)

Was a Chest Xray or CAT scan performed? (Enter 'Y' for Yes, and 'N' for No)

Was there radio evidence of pneumonia? (Enter 'Y' for Yes, and 'N' for No)

Date of 1st evaluation (MM/DD/YYYY)

Has the patient been hospitalized for at least 24 hours? (Enter 'Y' for Yes, and 'N' for No)

Name of hospital patient attended

City of hospital patient attended

State of the hospital the patient attended - abbreviation

Date of hospitalization (MM/DD/YYYY)

Date patient was discharged (MM/DD/YYYY)

Was the patient admitted to Intensive care? (Enter 'Y' for Yes, and 'N' for No)

Was the patient placed on ventilation? (Enter 'Y' for Yes, and 'N' for No)

Is the patient dead? (Enter 'Y' for Yes, and 'N' for No)

Date of death (MM/DD/YYYY)

Was an Autopsy Performed? (Enter 'Y' for Yes, and 'N' for No)

Was pneumonia or RDS found? (Enter 'Y' for Yes, and 'N' for No)

Was the patient a health care worker? (Enter 'Y' for Yes, and 'N' for No)

Type of health care worker

Direct patient care response

Occupation

Contact with SARS within 10 days? (Enter 'Y' for Yes, and 'N' for No)

Contact with RUI2 or 3? (Enter 'Y' for Yes, and 'N' for No)

CDC Contacted ID number

Contact state ID number

Name of contact

Classification of contact

Nature of contact

Contact start date (MM/DD/YYYY)

Contact end date (MM/DD/YYYY)

Did the patient travel to an area currenty known for SARS to be present? (Enter 'Y' for Yes, and 'N' for No)

Was a health alert recieved? (Enter 'Y' for Yes, and 'N' for No)

Was the patient symptomatic within 24 hours? (Enter 'Y' for Yes, and 'N' for No)

SARS suspect

Travel departure date (MM/DD/YYYY)

Departure city

Arrival city

Transport type

Specimen 1

Date specimen 1 collected (MM/DD/YYYY)

Test requested on specimen 1

Source of local test on specimen 1

Result of specimen 1

Specimen 2?

Date specimen 2 collected (MM/DD/YYYY)

Test requested on specimen 2

Source of local test on specimen 2

Result of specimen 2