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Patient Interview Tools

Public health officials may wish to gather additional information about possible exposures. This information helps detect both locally acquired and travel-related outbreaks, and also informs national surveillance statistics, which are used in policy development. The following resources can assist public health officials in the interview and investigation of single cases of disease.

 

Data-gathering Templates

  • Legionnaires’ Disease Hypothesis-generating Questionnaire Template
    Word [12 pages] | PDF [12 pages]
    Use or adapt this form to collect additional information about possible exposures to Legionella. These data may be useful in detecting or investigating outbreaks. You may add this form or components of this form to your state’s electronic notifiable disease surveillance system for routine data collection. A more detailed questionnaire customized to an outbreak location should be developed and completed for cases associated with a known outbreak.
  • Legionnaires’ Disease Cruise Ship Questionnaire Template
    Word [15 pages] | PDF [15 pages]
    Use or adapt this form to collect additional exposure data for cases that may be associated with a cruise ship.
  • Legionnaires’ Disease Medical Record Abstraction Form Template
    Word [8 pages] | PDF [8 pages]
    Use or adapt this form to collect additional clinical and epidemiologic data, or to help confirm and classify a case of Legionnaires’ disease in a patient with a complicated clinical history. For outbreaks in healthcare settings, you may customize this form to the outbreak location and complete it for confirmed or suspect cases associated with the outbreak.
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