Influenza A Case Investigation

Novel and Pandemic Influenza A Virus Infection Case Investigation Form

Case Information

Date of Report: _______/_______/_______(DD/MM/YYYY)

State/Local Case Identification Number: _____________________

CDC Case Identification Number: __________________________

Name of case-patient: Last ________________________ First_______________ Initials of case-patient (if not US case):_____________

Postal address: Street__________________________ Village/Town/City _________________________County/District_________________

State/Province____________ _______Zip Code/Postal Code_______________________

GIS coordinates of residence (Latitude Degrees/Minutes/Seconds X Longitude Degrees/Minutes/Seconds) _____________________________

Telephone #_____________________ Cell/Mobile _____________________ Fax _____________________ E-mail ___________________

Immigration status:  US resident  Resides abroad but visiting US

Reporter Information

Name of reporter: Last_____________________ First_____________________

Postal address: Street__________________________ City __________________ State/Province____________ Zip Code/Postal Code________

Telephone #_____________________ Cell/Mobile _____________________ Fax _____________________ E-mail ___________________

Reporter’s Organization:

State or County Health Department: _____________________ City_____________________ State/Province______________

Source of Information

 Case-patient

 Proxy; IF YES, relationship of proxy to case-patient_____________________ Reason for use of proxy_________________________________

Name of proxy: Last_____________________ First______________________

Postal address: Street__________________________ Village/Town/City _________________________County/District_________________

State/Province____________ _______Zip Code/Postal Code_______________________

Telephone #_____________________ Cell/Mobile _____________________ Fax _____________________

E-mail ___________________

Case-Patient Demographic Information

Date of Birth: _______/_______/_______(DD/MM/YYYY)

Race: White  Asian  American Indian/Alaska Native

 Black  Native Hawaiian/Other Pacific Islander  Unknown

Ethnicity:  Hispanic  Non-Hispanic  Unknown

Sex:  Male  Female

Social History and Contact Tracing

Number of household members (including case patient) _____________________

Does the case-patient have family members or close contacts with pneumonia or severe influenza-like-illness?

[close-contact defined as contact within 1 meter (or 3 feet) with a person (e.g. caring for, speaking with, or touching)]

 Yes (complete contact form)  No  N/A  Unknown

[If YES, list any identified contacts on the contact tracing form]

What is the current job of the case-patient? (check all that apply)

 Laboratory worker  Health care worker  Poultry farm-worker  Wildlife worker

 Veterinary worker  Other animal farm-worker

 Other________________  Other animal husbandry _________________________

How long has the case-patient worked in their current job? (number) _______________  months  years

If less than six months, list the type of job previously held: (specify job) ____________ (specify length of time at previous job) _________

Does the case-patient work in a health care facility or setting?

 Yes (specify name)___________________________  No  Unknown

Exposures- Travel history

In the 10 days prior to illness onset, did the case-patient travel?

 Yes  No  Unknown

If YES, please fill in the arrival and departure dates for all countries visited.

1. Country____________ Arrival__________ Departure__________

Mode of Transportation______________ Flight/Ship #______________

2. Country____________ Arrival__________ Departure__________

Mode of Transportation______________ Flight/Ship #______________

3. Country____________ Arrival__________ Departure__________

Mode of Transportation______________ Flight/Ship #______________

4. Country____________ Arrival__________ Departure__________

Mode of Transportation______________ Flight/Ship #______________

5. Country____________ Arrival__________ Departure__________

Mode of Transportation______________ Flight/Ship #______________

6. Country____________ Arrival__________ Departure__________

Mode of Transportation______________ Flight/Ship #______________

7. Country____________ Arrival__________ Departure__________

Mode of Transportation______________ Flight/Ship #______________

Exposures-Contact with probable or confirmed case-patients

In the 10 days prior to illness onset:

Did the case-patient have close contact (within 1 meter (or 3 feet)) with a person (e.g. caring for, speaking with, or touching) with fever and cough, or pneumonia, or that died of a respiratory illness in the 10 days prior to illness onset?

 Yes  No  Unknown

If YES, was the contact in the U.S.A. or international?

 US  International  Unknown

If International, in which country or countries?

County: _________________ Date(s) of Contact: _______________________________________________________

County: _________________ Date(s) of Contact: _______________________________________________________

In the 10 days prior to illness onset:

Did the case-patient have close contact (within 1 meter (3 feet)) with a person (e.g. caring for, speaking with, or touching) who is a suspected, probable or confirmed novel (including avian and pandemic) human influenza A case within the week prior to illness onset?

 YES  No  Unknown

If YES:

a. Did the patient directly touch or provide physical care for the probable or confirmed case?

 YES  No  Unknown

b. Did the patient speak to or touch or any items belonging to the probable or confirmed case?

 YES  No  Unknown

In the 10 days prior to illness onset:

Did the case-patient visit or stay in the same household with anyone who died during or following the visit?

 Yes  No  Unknown

If this case-patient has a diagnosis of novel influenza A virus infection that has not been laboratory confirmed, is there an epidemiologic link between this patient and a laboratory-confirmed or probable novel influenza A case?

 Yes  No  Unknown

In the 10 days prior to illness onset:

Did the case-patient seek care for an unrelated health condition in a healthcare facility known to be simultaneously caring for other suspected or confirmed human cases of avian or novel influenza?

 Yes  No  Unknown

Exposures-Contact with Poultry and Other Animals

Are any sick or dead animal(s) present in the case-patient’s home, village, neighborhood, or workplace?

 Yes  No  Unknown

If YES, which of following are present? (check all that apply)

 Chickens/poultry  Wild birds  Pigs  Other (specify)_______________________

If YES, what is the status of the animals during the two weeks prior to case-patient illness onset?

 Well-appearing  Diseased  Dead (approximate date of death) __________________

If there are sick poultry, are they vaccinated against influenza?

 Yes  No  Unknown

If there are sick pigs, are they vaccinated against influenza?

 YES  No  Unknown

In the 10 days prior to illness onset, did the case-patient have contact with any of the following animals? (check all that apply)

 Chickens/poultry  Wild birds  Pigs  Other (specify)_________________________________

If the patient had contact with animals, please answer the following questions, otherwise skip to the Medical History section:

What was the nature of the contact (check all that apply)?

 Direct touching (specify animal(s)) ____________

 Proximity within 1 meter but not touching (specify animal(s))______________

If the case-patient directly touched the bird(s) or other animal(s), which of the following did the patient do with the animal:

(check all that apply)

 Carry/handle  Slaughter/butcher  Prepare for consumption  Other (specify) _________________

If the case-patient directly touched the bird(s) or other animal(s), approximately how many sick or dead birds/animals did the patient touch?

 One only  2-5  6-20  21-100  >100

What species of bird(s) or other animal(s) did the case-patient come in contact with? (directly or within 1 meter)

Species #1_________________ Species #2_________________ Species #3_________________

What was the status of the bird(s) or other animal(s) during the two weeks PRIOR to case-patient illness onset?

 Well-appearing  Diseased  Dead (approximate date of death) ____________________________

What is the status of the bird(s) or other animal(s) AFTER the onset of illness in the case-patient?

 Well-appearing  Diseased  Dead (approximate date of death) ____________________________

Where did the contact occur? (check all that apply)

 Live animal market  Commercial animal farm  Backyard animals  Inside home

 Cockfighting  Slaughterhouse  Veterinary contact  Hunting

 Wildlife  Other contact___________________________

Are the bird(s) or other animal(s) that the case-patient came in contact with vaccinated with any of following influenza vaccines?

 H1  H3  H5  Not vaccinated  Unknown vaccination status

Was the contact in the US or international?

 US  International  Unknown

If contact was in the US, in which city and state did it occur?

City: ______________ State: ________________ Date: ______________

City: ______________ State: ________________ Date: ______________

If contact was international, in which country or countries did it occur?

City_______________ Province______________ Country: _________________ Dates: __________________

City_______________ Province______________ Country: _________________ Dates: __________________

Answer the remaining questions in this section in terms of the 10 days prior to the onset of the patient’s illness:

Did the case-patient touch (handle, slaughter, butcher, prepare for consumption) animals (including poultry, wild birds, or swine) or their remains in an area where influenza infection in animals or novel influenza in humans has been suspected or confirmed in the last month?

 Yes  No  Unknown

Was the case-patient exposed to animal (including poultry, wild birds, or swine) remains in an area where influenza infection in animals or novel influenza in humans has been suspected or confirmed in the last month?

 Yes  No  Unknown

Was the case-patient exposed to environments contaminated by to animal feces (including poultry, wild birds, or swine) in an area where influenza infection in animals or novel influenza in humans has been suspected or confirmed in the last month?

 Yes  No  Unknown

Did the case-patient consume raw or undercooked animals (including poultry, wild birds, or swine products) in an area where influenza infections in animals or novel influenza in humans has been suspected or confirmed in the last month?

 Yes  No  Unknown

Did the patient visit an agricultural event, farm, petting zoo or place where pigs live or were exhibited (state or county fair) in the last month?

 Yes  No  Unknown

Did the patient have direct contact with pigs at an agricultural event, farm, petting zoo or place where pigs were exhibited (state or county fair) in the last month?

 Yes  No  Unknown

Did the case-patient handle samples (animal or human) suspected of containing influenza virus in a laboratory or other setting?

 Yes  No  Unknown

Medical History-Vaccination Status

Was the case-patient vaccinated against human influenza in the past year?

 Yes  No  Unknown

If YES, date of vaccination ____/____/____

Type of vaccine:  Inactivated  Live Attenuated  Unknown

Was the case-patient vaccinated against avian influenza A (H5N1)?

 Yes  No  Unknown

If YES, date of vaccination: ____/____/____

Type of vaccine: _________________

Medical History-Past Medical History

Is the case-patient pregnant?

 Yes (weeks pregnant)____________  No  Unknown

Does the case-patient have any of the following?

a. Asthma  yes  no  unknown

2. Other chronic lung disease  yes  no  unknown (If YES, specify) _______________________

3. Chronic heart or circulatory disease  yes  no  unknown (If YES, specify) _______________________

4. Metabolic disease (including diabetes mellitus)  yes  no  unknown (If YES, specify) _______________________

5. Kidney disease  yes  no  unknown (If YES, specify) _______________________

6. Cancer in the last 12 months  yes  no  unknown (If YES, specify) _______________________

7. Immunosuppressive condition (such as HIV infection, cancer, chronic corticosteroid therapy, diabetes, or organ transplant recipient)

 yes  no  unknown (If YES, specify) _______________________

2. Other chronic diseases  yes  no  unknown (If YES, specify) _______________________

Is the case-patient on chronic drug therapy?

 Yes  No  Unknown

If yes, complete table below

Drug	Dose	Frequency	Date Initiated
	mg
	mg
	mg
	mg
	mg

Has the case-patient smoked at least 100 cigarettes in their life? (100 cigarettes = approximately 5 packs)  yes  no  unknown

If YES, does the patient now smoke cigarettes:  everyday  some days  not at all

Medical History-Illness onset and presenting symptoms

Date of illness onset _________________ (DD/MM/YYYY)

Date(s) of outpatient medical presentation(s) (clinic location, name):

Clinic #1 name: __________________ Date(s): _________________ (DD/MM/YYYY) Telephone #: _____________ Fax #: __________________

Address: __________________________________________________________________________

Clinic #2 name: __________________ Date(s): _________________ (DD/MM/YYYY) Telephone #: _____________ Fax #: __________________

Address: __________________________________________________________________________

Date(s) of hospital admission(s):

Hospital #1 Name: _______________________ Telephone#______________________ Fax #: ____________________

Address: __________________________________________________________________________________

Admission date: __________________ (DD/MM/YYYY)

 Discharged (specify date) ______________________  Transferred (specify date) ___________

Hospital #2 Name: _______________________ Telephone#______________________ Fax #: ____________________

Address: __________________________________________________________________________________

Admission date: __________________ (DD/MM/YYYY)

 Discharged (specify date) ______________________  Transferred (specify date) ___________

Within the last 7 days, has the case-patient experienced any of the following medical conditions:

1. Coughing  YES  NO  Unknown

2. Diarrhea  YES  NO  Unknown

3. Difficulty breathing  YES  NO  Unknown

(or shortness of breath)

4. Eye infection  YES  NO  Unknown

5. Fever (_____°) temp if known  YES  NO  Unknown

6. Feverishness  YES  NO  Unknown

7. Headache  YES  NO  Unknown

8. Muscle aches  YES  NO  Unknown

9. Rash  YES  NO  Unknown

10. Runny nose  YES  NO  Unknown

11. Seizures  YES  NO  Unknown

12. Sore throat  YES  NO  Unknown

13. Vomiting  YES  NO  Unknown

14. Other symptom(s)  YES  NO (specify)________________________

Medical History-Treatment, Clinical Course, and Outcome

Did the case-patient receive antiviral medications?

 Yes  No  Unknown

If yes, complete table below

Drug	Dose # 1	Dose #1 Date Initiated (DD/MM/YYYY)	Dose #1 Date Discontinued (DD/MM/YYYY)	Dose #2	Dose #2 Date Initiated (DD/MM/YYYY)	Dose #2 Date Discontinued (DD/MM/YYYY)
Oseltamivir	mg			mg
Zanamivir	mg			mg
Rimantadine	mg			mg
Amantadine	mg			mg
Other ____________

Did the case-patient receive antibacterial medications?

 Yes  No  Unknown

If yes, complete table below

Drug	Date Initiated	Date Discontinued	Dosage (if known)
			mg
			mg
			mg
			mg

Did the case-patient receive steroids?

 Yes  No  Unknown

If yes, complete table below

Drug	Date Initiated	Date Discontinued	Dosage (if known)
			mg
			mg

Did the case-patient receive aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs)?

 Yes  No  Unknown

If yes, complete table below

Drug	Date Initiated	Date Discontinued	Dosage (if known)
			mg
			mg

Was the case-patient admitted to an intensive care unit (ICU)?

 Yes  No  Unknown

Did this case-patient receive mechanical ventilation?

 Yes  No  Unknown

Did the case-patient have acute respiratory distress syndrome (ARDS)?

 Yes  No  Unknown

What was the outcome for the case-patient?

 Alive  Died  Unknown

If the patient is ALIVE, what is the current disposition of the case-patient?

 Still hospitalized  Discharged to home  Discharged to nursing care facility (specify name) ___________________

 Unknown  Other (specify) ___________________

If the patient DIED, please list date of death _______________________(DD/MM/YYYY)

List the ICD-9CM diagnoses at ADMISSION and for each indicate if the diagnosis is a new diagnosis.

1. _ _ _. _ _  New  Unknown 4. _ _ _. _ _  New  Unknown

2. _ _ _. _ _  New  Unknown 5. _ _ _. _ _  New  Unknown

3. _ _ _. _ _  New  Unknown 6. _ _ _. _ _  New  Unknown

List the ICD-10 diagnoses at ADMISSION and for each indicate if the diagnosis is a new diagnosis.

1. _ _ _. _ _  New  Unknown 4. _ _ _. _ _  New  Unknown

2. _ _ _. _ _  New  Unknown 5. _ _ _. _ _  New  Unknown

3. _ _ _. _ _  New  Unknown 6. _ _ _. _ _  New  Unknown

List the ICD-9CM diagnoses at discharge and for each indicate if the diagnosis is a new sequelae of this hospitalization

1. _ _ _. _ _  New  Unknown 4. _ _ _. _ _  New  Unknown

2. _ _ _. _ _  New  Unknown 5. _ _ _. _ _  New  Unknown

3. _ _ _. _ _  New  Unknown 6. _ _ _. _ _  New  Unknown

List the ICD-10 diagnoses at discharge and for each indicate if the diagnosis is a new sequelae of this hospitalization

1. _ _ _. _ _  New  Unknown 4. _ _ _. _ _  New  Unknown

2. _ _ _. _ _  New  Unknown 5. _ _ _. _ _  New  Unknown

3. _ _ _. _ _  New  Unknown 6. _ _ _. _ _  New  Unknown

If ICD-9CM or ICD-10 diagnoses at ADMISSION are not available, write in diagnosis and indicate if the diagnosis is a new diagnosis.

1. _________________________  New  Unk 4. _________________________  New  Unk

2. _________________________  New  Unk 5. _________________________  New  Unk

3. _________________________  New  Unk 6. _________________________  New  Unk

If ICD-9CM or ICD-10 diagnoses at DISCHARGE are not available, write in diagnosis and indicate if the diagnosis is a new sequelae of this hospitalization.

1. _________________________  New  Unk 4. _________________________  New  Unk

2. _________________________  New  Unk 5. _________________________  New  Unk

3. _________________________  New  Unk 6. _________________________  New  Unk

Medical History-Laboratory and Diagnostic Testing

Did the case-patient have a chest x-ray or chest CT scan performed?

 Yes  No  not performed  Unknown

If YES, which test was performed? (check all that apply)

 Chest CT  Chest X-ray

If either test was performed, what was the result?

 Normal  Abnormal  Unknown

If abnormal, was there evidence of pneumonia?

 Yes  No  Unknown

Did the case-patient have a CT scan/MRI of the head or brain?

 Yes  No  not performed  Unknown

If YES, were there any acute neurologic abnormalities?

 Yes  No  Unknown

List the following laboratory test results UPON initial admission:

White blood cell (WBC) count __________________  Unknown

Lymphocyte count __________________  Unknown

Neutrophil count __________________  Unknown

Platelet count __________________  Unknown

Did the patient have any of the following laboratory abnormalities at any time during the hospitalization?

Leukopenia (white blood cell count <5,000 leukocytes/mm3)

 Yes  No  Unknown

Lymphopenia (total lymphocytes <800/mm3 or lymphocytes <15% of total WBC)

 Yes  No  Unknown

Thrombocytopenia (total platelets <150,000/mm3)

 Yes  No  Unknow

Were bacterial cultures performed?

 Yes  No  Unknown

If YES, were any positive?

If positive, complete table below

Site (Urine, Blood, CSF, Pleural, Ascitic)	Date Performed	Date Positive	Organism grown

Were non-influenza viral tests performed?

 Yes  No  Unknown

If yes, complete table below

Site (Urine, Blood, CSF, Pleural, Ascitic)	Date Performed	Result	Organism

Influenza Specific Diagnostic tests:

Test 1

Specimen type:

 NP swab  NP aspirate  Nasal swab  Nasal aspirate  Sputum

 Oropharyngeal swab  Endotracheal aspirate  Chest tube fluid

 Broncheoalveolar lavage specimen (BAL)  Serum

 Other

Date collected: __/__/__

	RT-PCR Yes or No	Direct fluorescent antibody (DFA)	Viral culture	Rapid antigen test	CDC RT-PCR
Influenza A	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested
H1	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested		 Negative  Positive  Inconclusive  Pending  Not tested
H3	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested		 Negative  Positive  Inconclusive  Pending  Not tested
H5	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested		 Negative  Positive  Inconclusive  Pending  Not tested
H7	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested		 Negative  Positive  Inconclusive  Pending  Not tested
Influenza B	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested

Test type and result: (check all boxes that apply)

Test Location if not Hospital Laboratory______________________

Test 2

Specimen type:

 NP swab  NP aspirate  Nasal swab  Nasal aspirate  Sputum

 Oropharyngeal swab  Endotracheal aspirate  Chest tube fluid

 Broncheoalveolar lavage specimen (BAL)  Serum

 Other

Date collected: __/__/__

Test type and result: (check all boxes that apply)

	RT-PCR Yes or No	Direct fluorescent antibody (DFA)	Viral culture	Rapid antigen test	CDC RT-PCR
Influenza A	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested
H1	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested		 Negative  Positive  Inconclusive  Pending  Not tested
H3	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested		 Negative  Positive  Inconclusive  Pending  Not tested
H5	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested		 Negative  Positive  Inconclusive  Pending  Not tested
H7	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested		 Negative  Positive  Inconclusive  Pending  Not tested
Influenza B	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested

Test Location if not Hospital Laboratory______________________

Test 3

Specimen type:

 NP swab  NP aspirate  Nasal swab  Nasal aspirate  Sputum

 Oropharyngeal swab  Endotracheal aspirate  Chest tube fluid

 Broncheoalveolar lavage specimen (BAL)  Serum

 Other

Date collected: __/__/__

Test type and result: (check all boxes that apply)

	RT-PCR Yes or No	Direct fluorescent antibody (DFA)	Viral culture	Rapid antigen test	CDC RT-PCR
Influenza A	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested
H1	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested		 Negative  Positive  Inconclusive  Pending  Not tested
H3	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested		 Negative  Positive  Inconclusive  Pending  Not tested
H5	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested		 Negative  Positive  Inconclusive  Pending  Not tested
H7	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested		 Negative  Positive  Inconclusive  Pending  Not tested
Influenza B	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested	 Negative  Positive  Inconclusive  Pending  Not tested

Test Location if not Hospital Laboratory______________________

Specimen Tracking

Indicate when and what type of specimens (including sera) were sent to CDC and CDCID number, if known

__/__/__ Specimen type _________________CDCID#_________________

__/__/__ Specimen type _________________CDCID#_________________

__/__/__ Specimen type _________________CDCID#_________________