8a Follow Up Assessment

Study ID: __ __ __ __ __ __ __ __ __ __
CEIRS Human Influenza Surveillance Study
Form 8A: Follow-up Assessment
1. How many attempts were made?
__________ attempts
At most 4 attempts of phone follow-up should be made unless requested otherwise by subject.
Attempt 1:
Date: _____ / ______ / ______ (mm/dd/yyyy)
Time: _____ / ______ / ______ (hh:mm) (24-hour clock)

□ No

Successful Contact:

□ Yes

Attempt 2:
Date: _____ / ______ / ______ (mm/dd/yyyy)
Time: _____ / ______ / ______ (hh:mm) (24-hour clock)

□ No

Successful Contact:

□ Yes

Attempt 3:
Date: _____ / ______ / ______ (mm/dd/yyyy)
Time: _____ / ______ / ______ (hh:mm) (24-hour clock)

□ No

Successful Contact:

□ Yes

Attempt 4:
Date: __ __ / __ __ / __ __ __ __
Time: __ __: __ __ (hh:mm)(24-hour clock)

□ No

Successful Contact:

2. Did the follow-up assessment occur?
If Yes, specify date:

□ Yes

□ No □ Yes

_____ / ______ / _______ (mm/dd/yyyy)

If Yes, how did the follow-up occur?

□ In-person □ Telephone

If No, specify reason:
_____ Subject unavailable for follow-up
_____ Minimum of 4 failed attempts at phone follow-up
_____ Contact numbers non-functional
_____ Subject requested no further contact
_____ Other, specify: ___________________________
If the Follow-up was performed via the phone, please use the following script:
“Hello Mr. /Ms. (Insert Subject Last Name)
My name is (Insert Research Coordinator Name), I am [calling] from the Emergency Department at (Insert
Name of Medical Center) where you were seen about 3 weeks ago. At that time, you agreed to enroll in
our study on influenza testing in the emergency department. As part of this research study we are
following up with you. The purpose of this call is to get some more information from you regarding your
illness and the outcome.
Are you still willing to answer a few questions?”

□ No □ Yes

If No, stop
If Yes, research coordinator proceeds with the follow-up assessment questions:
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Form 8A: Follow Up

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Study ID: __ __ __ __ __ __ __ __ __ __
Follow-up Assessment Questions
1. Have you returned to an Emergency Department since you were enrolled in this study?

□ No

□ Yes

□ Unknown

a. If Yes, how many times? _______
What was the approximate date and the reason you came to the ED? (Record up to 3 visits):
ED Visit 1
Which ED was it?

□ JHH
□ BVMC
□ Linkou
□ Keelung □ Other □ Unknown

□ Taipei

Date: __ __ / __ __ / __ __ __ __ (mm/dd/yyyy)
Reason: _______________________________
ED Visit 2
Which ED was it?

□ JHH
□ BVMC
□ Linkou
□ Keelung □ Other □ Unknown

□ Taipei

Date: __ __ / __ __ / __ __ __ __ (mm/dd/yyyy)
Reason: ________________________________
ED Visit 3
Which ED was it?

□ JHH
□ BVMC
□ Linkou
□ Keelung □ Other □ Unknown

□ Taipei

Date:__ __ / __ __ / __ __ __ __ (mm/dd/yyyy)
Reason: ________________________________
2. Have you been admitted to the hospital (stayed overnight) since you were enrolled in this study?

□ No

□ Yes

□ Unknown

a. If Yes, how many times? _______
What was the approximate date and the reason for your hospitalizations? (Record up to 3 visits):
Hospitalization 1
Admit Date: __ __ / __ __ / __ __ __ __ (mm/dd/yyyy)
Reason: ________________________________
Length of Stay ___________________________
Hospitalization 2
Admit Date: __ __ / __ __ / __ __ __ __ (mm/dd/yyyy)
Reason: ________________________________
Length of Stay ___________________________
Hospitalization 3
Admit Date: __ __ / __ __ / __ __ __ __ (mm/dd/yyyy)
Reason: ________________________________
Length of Stay ___________________________

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Form 8A: Follow Up

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Study ID: __ __ __ __ __ __ __ __ __ __

3. Following the ED visit during which you were enrolled in this study, did you receive any antiviral medications
to treat influenza? (Note: Do not include any antiviral medications that were prescribed during the initial ED
visit)

□ No

□ Yes

□ Unknown

a. If yes, What influenza antirviral treatment did you take?

□ Zanamavir
□ Oseltamivir
□ Amantadine
□ Rimantadine
□ Other, specify; ____________________
□ Unknown
□ None
b. If yes, Date antiviral was started: __ __ / __ __ / __ __ __ __ (mm/dd/yyyy)
Duration taken for: _________ days
4. Following the ED visit during which you were enrolled in this study, did you receive any antibiotic
medications? (Note: Do not include any antibiotic medications that were prescribed during the initial ED
visit)

□ No

□ Yes

□ Unknown

a. If yes, how many did you take? _______ (Record up to three)
Antibiotic 1
Name of antibiotic received: ______________________
Date antibiotic was started:__ __ / __ __ / __ __ __ __
Duration taken for: _______ days
Antibiotic 2
Name of antibiotic received: ______________________
Date antibiotic was started:__ __ / __ __ / __ __ __ __
Duration taken for: ______ days
Antibiotic 3
Name of antibiotic received: ______________________
Date antibiotic was started: __ __ / __ __ / __ __ __ __
Duration taken for: ______ days
5. Have you been diagnosed with a heart attack since you were enrolled in this study?

□ No

□ Yes

□ Unknown

6. Have you been diagnosed with a stroke since you were enrolled in this study?

□ No

□ Yes

□ Unknown

a. If yes, date of stroke diagnosis: __ __ / __ __ / __ __ __ __ (mm/dd/yyyy)
7. Have you been diagnosed with pneumonia since you were enrolled in this study?

□ No
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□ Yes
Form 8A: Follow Up

□ Unknown
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Study ID: __ __ __ __ __ __ __ __ __ __
Follow up Blood (Serum) Sample
Blood (Serum) Sample:

□ Collected
□ Patient refused: Reason _________________________
□ Phone follow up – unable to obtain successful contact
□ Coordinator Unable to Obtain: Reason _________________________
□ Other:_________________________

If collected:

Collection:
Date: __ __ / __ __ / __ __ __ __
Time: __ __ : __ __ (hh:mm) (24-hour clock)
Coordinator initials: _________
Placed in refrigerator:
Date: __ __ / __ __ / __ __ __ __
Time: __ __ : __ __ (hh:mm) (24-hour clock)
Coordinator initials: _________
Final sample processing:
Date: __ __ / __ __ / __ __ __ __
Time: __ __ : __ __ (hh:mm) (24-hour clock)
Coordinator initials: _________

Subject notes:

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Form 8A: Follow Up

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