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Epidemiology in the Classroom » How to Investigate an Outbreak
Appendix


Background Information Required for Student Exercises

*Exercise 3: Case Report Forms

State Disease Report Form

State Disease Report Form
Name
McDowell, D.
Age
33
Phone
555-3707
Address
2020 Alabama 
Sex
M
Race
W
City, State
Columbia
County
Columbia
Disease
 Trichinosis
Date of Onset
7/27
Lab Confirmation
Muscle Biopsy
Hospital Alerted?
Yes
Hospital Name
Columbia General
Admission Date
7/27
Discharge Date
Lab Test Results
 Eosinophilia = 2500  
Comments (Clinical description, immunization theory, etc.)

Possible Exposure Cleveland-McKay Wedding

Physician Reporting
Dr. Baker 
Phone
555-1900
Date of Report
8/17

 

State Disease Report Form
Name
Gordon, Jack
Age
26
Phone
555-1213
Address
110 Clifton St. 
Sex
M
Race
W
City, State
Columbia
County
Columbia
Disease
Probable Trichinosis
Date of Onset
8/14
Lab Confirmation
Not Done
Hospital Alerted?
No
Hospital Name Admission Date Discharge Date
Lab Test Results
Eosinophilia = 37% 
Comments (Clinical description, immunization theory, etc.)

Possible Exposure Cleveland-McKay Wedding

Physician Reporting
Dr. Gibbs  
Phone
555-3841
Date of Report
8/14

 

State Disease Report Form
Name
Thomas, Nancy
Age
27
Phone
555-3761
Address
2020 Alabama 
Sex
F
Race
W
City, State
Columbia
County
Columbia
Disease
 Trichinosis
Date of Onset
8/4
Lab Confirmation
Not Done
Hospital Alerted?
No
Hospital Name Admission Date Discharge Date
Lab Test Results
Eosinophilia = 18% 
Comments (Clinical description, immunization theory, etc.)

Possible Exposure Cleveland-McKay Wedding

Physician Reporting
Dr. Stanley  
Phone
555-0400
Date of Report
8/14

 

State Disease Report Form
Name
Dickens, R.
Age
43
Phone
555-2662
Address
34 Whinfred Ave. 
Sex
M
Race
W
City, State
Seattle, WA
County
King
Disease
 Trichinosis
Date of Onset
7/25
Lab Confirmation
Serologic
Hospital Alerted?
No
Hospital Name Admission Date Discharge Date
Lab Test Results
Eosinophilia = 4100
Comments (Clinical description, immunization theory, etc.)

Possible Exposure Cleveland-McKay Wedding

Physician Reporting
Dr. Webster
Phone
555-0511
Date of Report
8/15

 

State Disease Report Form
Name
McKay, Alice
Age
54
Phone
555-6256
Address
406 Tugalo Ln.
Sex
F
Race
W
City, State
Brighton
County
Clayton
Disease
R/O Trichinosis
Date of Onset
8/14
Lab Confirmation
Not Done
Hospital Alerted?
Yes
Hospital Name
Columbia General
Admission Date
8/14
Discharge Date
Lab Test Results
Eosinophilia = 3600
Comments (Clinical description, immunization theory, etc.)

Possible Exposure Cleveland-McKay Wedding

Physician Reporting
Dr. Mason  
Phone
555-3291
Date of Report
8/15

 

  Rash No Rash Total

Exposed to Celery?

Yes 25 31 56
No 5 65 70
  Total 30 96 126 

*Exercise 5: Data on exposure to celery

Back to How to Investigate an Outbreak 





This page last reviewed November 17, 2004

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