Data Collection Forms

The resources below can be used to collect information relevant to identifying etiologies of respiratory outbreaks. Do not use these forms to report a disease outbreak to CDC. For reporting assistance, please refer to your state health department.

Long Form

The Data Collection—Long Form pdf icon[13 pages] provides a comprehensive set of questions to consider using when developing a case questionnaire. These questions cover a range of topic areas including:

• Patient and family contact information
• Occupation
• Travel history and other exposures of interest
• Extensive past medical history review
• A comprehensive list of potential laboratory tests completed

It would be unusual to use the long form in its entirety for any particular outbreak. Instead, use pieces of the form based on factors surrounding the outbreak, including the differential diagnoses and the population affected.

Information needed to answer many of the questions on the long form may not be available. In addition, investigators may need to compile information from several sources, such as:

• Medical records
• Physician, patient, and family interviews
• Public health partners

Short Form

The Data Collection—Short Form pdf icon[2 pages] collects common or “core” data elements needed in most respiratory disease outbreak investigations. Modify the form as necessary to accommodate the particular data requirements of the current outbreak investigation.

The first page of the form allows for collection of basic demographic, symptom, and exposure information from a patient interview. The second page collects objective clinical and laboratory testing information. You can collect this information by interviewing the treating or reporting physician or by reviewing the ill person’s medical record.