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. |
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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 |
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II. Case-Patient’s Demographics |
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Residence: County: State: 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
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III. Laboratory Information |
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Did the specimen(s) have a positive or negative test result? ☐ Positive ☐ Negative ☐ Unknown Please specify what test type was completed (per specimen):
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 |
Form Approved OMB Control No.: 0920-1360 Expiration date: 1/31/2025 |
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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: |
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Yes |
No |
Unknown |
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Travel (outside of the area where he/she lives or works/goes to school): |
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Internationally? |
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Domestically? |
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If Yes for either, please specify: |
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Swim in, play in, wade in, or enter a/an: |
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Ocean? |
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Natural hot spring? |
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Lake, pond, river, or stream? |
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Swimming pool or kiddie/wading pool? |
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If Swimming pool, please specify type: |
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Water playground, interactive fountain, splash pad, or spray park? |
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Hot tub, spa, whirlpool, or Jacuzzi? |
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Other recreational water source? |
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Other, specify: |
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Consume water from: |
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Municipal/public supply (i.e., does case-patient receive water bill from public or private utility)? |
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Private well (e.g., used by 1 household)? |
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Common well (e.g., used by >1 household)? |
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Commercially Bottled water? |
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Spring, lake, creek, river, stream, or cistern (i.e., untreated surface water)? |
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Other drinking water source? |
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Other, specify |
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Consume raw/unpasteurized milk or dairy products? |
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Consume raw/unpasteurized fruit or vegetable juice or cider? |
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Attend any large gatherings (e.g., wedding, party/picnic, festival/fair, or sports event)? |
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Have contact with children in a childcare setting? |
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Have contact with diapered children or adult(s)? |
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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? |
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Have contact with animal manure, pet feces, or compost? |
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Have contact with a: |
Yes |
No |
Unknown |
Cow? |
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Calf (baby cow)? |
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Sheep? |
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Lamb (baby sheep)? |
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Goat? |
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Kid (baby goat)? |
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Horse? |
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Foal (baby horse)? |
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Cat? |
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Kitten? |
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Dog? |
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Puppy? |
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Squirrel? |
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(Deer) mouse? |
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Raccoon? |
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Chipmunk? |
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Chicken? |
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Chick (baby chicken)? |
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Turkey? |
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Poult (baby turkey)? |
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Other animal? |
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Other, specify: |
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Have sexual contact with a: |
Yes |
No |
Unknown |
Male? |
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Female? |
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General remarks:
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Perez, Ariana (CDC/DDID/NCEZID/DFWED) |
File Modified | 0000-00-00 |
File Created | 2025-01-11 |