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Content on this page was developed during the 2009-2010 H1N1 pandemic and has not been updated.

  • The H1N1 virus that caused that pandemic is now a regular human flu virus and continues to circulate seasonally worldwide.
  • The English language content on this website is being archived for historic and reference purposes only.
  • For current, updated information on seasonal flu, including information about H1N1, see the CDC Seasonal Flu website.

Clinical Data Collection Forms and Templates for Collection of Information on Patients Infected with Novel Influenza A (H1N1)

May 12, 2009 3:00 PM ET

This page is designed to give clinicians access to the latest guidelines and information on the evolving novel H1N1 influenza investigation.

CDC Clinical Data Collection Forms and Templates for Collection of Information on Patients Infected with Novel Influenza A (H1N1)

The following novel Influenza A (H1N1) data collection forms are being made available for use by public health officials, and for researchers and clinicians in the medical and academic communities both in the United States and in other countries. These templates represent a variety of data collection instruments that can be used to collect information on persons with novel Influenza A H1N1 infection. The data obtained from these instruments can help characterize the disease spectrum and severity, and help to understand what factors may increase the risk for more severe disease, and may guide healthcare decisions and resource allocation. 

This website will be updated as new forms become available.

H1N1 Influenza Case Report Form, v3.050109

Word Format

This form asked for limited information on cases and is a subset of the information requested in the “Novel Influenza Case Investigation Form” below. US state health departments have been asked to complete this form for individual cases and send the information to the CDC.

Addendums:

Novel Influenza Case Investigation Form, v 050209  

Word Format
This form provides for the collection of more detailed information on cases on all cases.

Influenza Investigation, Contact Tracing, v 050209

Word Format
This form provides for the collection of detailed information on persons who are contacts of ill persons and also collects information that can be used to assess the type and intensity of a persons exposure to an ill person.

Novel Influenza A: Clinical Description of Hospitalized Cases, version 28 April 2009

Word Format
This form was approved by CDC Institutional Review Board (IRB) (the CDC ethics review board) with IRB approval that expires 24 April 2010. This form provides for the collection of detailed clinical data on persons who are hospitalized cases with novel influenza A (H1N1) infection.

Addendums:

 
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