CryptoNet Case Report Form

[NCEZID] CryptoNet Case Report Form

Att C_CryptoNet Case Report Form_2024 version - CLEAN

CryptoNet Case Report Form

OMB: 0920-1360

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Form Approved OMB Control No.: 0920-1360

Expiration date: 1/31/2028

CryptoNet Case Report Form

All fields to be completed by state and local health department partners. Please contact CryptoNet staff at cryptonet@cdc.gov with any questions.

I. Case Report ID & Investigator Information


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State Case Laboratory ID State Case Epidemiology ID NNDSS Case ID

NORS ID

Outbreak status: Sporadic (not outbreak-associated) case Outbreak-associated case Unknown

II. Case-Patient’s Demographics

Shape2 Shape3

Residence: County: State:

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Age: (choose one) Years Months Days Sex: Female Male Unknown

What is the race and/or ethnicity of this person? (Select all that apply):

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Unknown

Declined to Answer


III. Laboratory Information

Did the specimen(s) have a positive or negative test result? Positive Negative Unknown Please specify what test type was completed (per specimen):


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Test used

Specimen Collection Date

MM/DD/YYYY

Biofire/ Torch

PCR

Luminex GPP

GI/Enteric

Panel

DFA

EIA

ImmunoCard STAT Crypto/Giardia

Other,

specify

Specimen 1










Specimen 2










Specimen 3










Specimen 4

























Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia

30333; ATTN: PRA 0920-1360

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Form Approved OMB Control No.: 0920-1360 Expiration date: 1/31/2025

IV. Symptom Onset & Exposure History


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Symptom onset date:

Patient deceased: Yes No Unknown


Symptoms of cryptosporidiosis generally begin 2 to 10 days (average 7 days) after infection and last 1 to 2 week. In 14 days before symptom onset, did the case-patient:



Yes

No

Unknown


Travel (outside of the area where he/she lives or works/goes to school):




Internationally?

Domestically?




If Yes for either, please specify:


Swim in, play in, wade in, or enter a/an:




Ocean?

Natural hot spring?




Lake, pond, river, or stream?




Swimming pool or kiddie/wading pool?




If Swimming pool, please specify type:


Water playground, interactive fountain, splash pad, or spray park?




Hot tub, spa, whirlpool, or Jacuzzi?




Other recreational water source?




Other, specify:


Consume water from:




Municipal/public supply (i.e., does case-patient receive water bill

from public or private utility)?

Private well (e.g., used by 1 household)?




Common well (e.g., used by >1 household)?




Commercially Bottled water?




Spring, lake, creek, river, stream, or cistern (i.e., untreated

surface water)?




Other drinking water source?




Other, specify


Consume raw/unpasteurized milk or dairy products?




Consume raw/unpasteurized fruit or vegetable juice or cider?




Attend any large gatherings (e.g., wedding, party/picnic, festival/fair, or sports event)?




Have contact with children in a childcare setting?




Have contact with diapered children or adult(s)?





Shape8 Form Approved OMB Control No.: 0920-1360 Expiration date: 1/31/2025

Visit, work, or live on farm, ranch, petting zoo, or other setting that has farm animals?




Have contact with animal manure, pet feces, or compost?




Have contact with a:

Yes

No

Unknown

Cow?




Calf (baby cow)?




Sheep?




Lamb (baby sheep)?




Goat?




Kid (baby goat)?




Horse?




Foal (baby horse)?




Cat?




Kitten?




Dog?




Puppy?




Squirrel?




(Deer) mouse?




Raccoon?




Chipmunk?




Chicken?




Chick (baby chicken)?




Turkey?




Poult (baby turkey)?




Other animal?




Other, specify:


Have sexual contact with a:

Yes

No

Unknown

Male?




Female?




General remarks:






File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPerez, Ariana (CDC/DDID/NCEZID/DFWED)
File Modified0000-00-00
File Created2025-01-11

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