Hospitalized Seasonal Influenza Report
INITIAL SUMMARY
UPDATE/AMENDMENT
FINAL SUMMARY
FAX completed form to Alberta Health, CD: 780-415-9609
SECTION 1: CASE DEFINITION
Confirmed Influenza Case:
Influenza A
Influenza B
Influenza A Strain Subtyped:
H1
H3
H5
H7
A(H1N1)pdm09
Other specify: Enter text here
SECTION 2: REPORTING INFORMATION
Date case investigation opened: Choose a date
Submitter: Enter text here
Telephone number: Enter text here
Date reported to Alberta Health:
Choose a date
FNIHB location Reporting: Choose one
Outbreak Associated?
No
Yes If Yes: EI#: Enter text here
SECTION 3: PERSONAL IDENTIFIERS
PHN: Enter text here
Name: Last Enter text here
Address: Enter text here
Province: Enter text here
Gender:
Ethnicity:
First Nations
Inuit
Caucasian
Black
Male
Female
Other
Unknown
Birth Date: mm/dd/yyyy
First
Enter text here
Municipality: Enter text here
Postal Code: Enter text here
Country: Enter text here
Lives on Reserve
No
Yes
Métis
Latin American
Asian
Other Asian
Middle Eastern
Unknown
Other, Specify:
Enter text here
SECTION 4: CLINICAL FINDINGS
Onset Date: Choose a date
Unable to contact
Was client hospitalized
Yes
No
Admitted to ICU?
Yes
No
Ventilated during any of the hospital stay(s)?
Yes
No
Died From disease
Fatal  Death Date: Choose a date
Influenza contributed to death (secondary cause)
Autopsy Performed?
Yes
No
Lost to follow-up
Unknown
Unknown
Unknown
Died – other causes
Died – unknown cause
Unknown
SECTION 5: SEASONAL INFLUENZA VACCINE HISTORY
Did the patient receive the previous seasonal influenza vaccine?
Did the patient receive the current seasonal influenza vaccine?
Comments: Enter text here
© 2009–2015 Government of Alberta
Alberta Health, September 2015
Yes
Yes  Choose a date
No
No
Unknown
Unknown