OHHABS Human Form

One Health Harmful Algal Bloom System (OHHABS) Human Form
Form Approved
OMB No. 0920-1105
Exp. Date: 11/30/2025

One Health Harmful Algal Bloom System (OHHABS)

Human Form

Public reporting burden of this collection of information is estimated to average 8 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 Information Collection Review Office,
1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-1105). DO NOT MAIL FORMS TO THIS ADDRESS

CDC REPORT ID

CDC FORM ID

STATE REPORT ID

REPORT DATE CREATED

GENERAL INFORMATION
Date illness reported to Health Department (MM/DD/YYYY):__________
Date of interview (MM/DD/YYYY):_________
HUMAN DESCRIPTION
Age:__________ ☐Years ☐Months
Sex:__________
State of Residence:__________
County of Residence:__________
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
HUMAN EXPOSURE INFORMATION
Did exposure to algae, cyanobacteria, or toxins occur on a single date or multiple dates? (MM/DD/YYYY) (Select one)
☐Single date
Date of exposure:__________
☐Multiple dates
Date of first exposure:__________
Date of last exposure:__________
☐Unknown
Was this an occupational/volunteer exposure?
☐Yes ☐No ☐Unknown
[If yes] Specify the occupation: __________
Is the setting of the exposure the same as the HAB event reported?
☐Yes ☐No ☐Unknown
EXPOSURE SOURCE
What was the source of the exposure? (Select all that apply)
☐Food ☐Water (including aerosols) ☐Other(specify):__________ ☐Unknown
[If food] FOOD EXPOSURES
What was the food exposure? (Select all that apply)
☐Fish (specify): __________
☐Other (e.g., supplements) (specify): __________
☐Shellfish (specify): __________
☐Unknown
☐Produce (specify): __________
[If fish/shellfish] Was it commercially or non-commercially harvested?
☐Non-commercially (self-harvested)
☐Commercially (consumed in a regulated
☐Unknown
setting, e.g., restaurant)
WATER AND OTHER EXPOSURES
[If Water or Other] How did the exposure occur?
Direct contact with skin or eyes (e.g., swimming)
☐ Yes
☐No
☐Unknown
Ingestion (e.g., drinking from waterbody)
☐ Yes
☐No
☐Unknown
Aerosol inhalation (e.g., watersports, walking near the shore)
☐ Yes
☐No
☐Unknown

Other (specify): __________
☐Unknown
WATER EXPOSURE ACTIVITY
Participation in direct contact water activities or watersports (e.g., swimming, diving, snorkeling, tubing, water skiing, etc.)
☐ Yes
☐No
☐Unknown
Participation in indirect/limited contact water activities or watersports (e.g., boating, fishing, kayaking, canoeing, etc.)
☐ Yes
☐No
☐Unknown
Participation in other activities (e.g., hiking, walking, etc.)
☐ Yes
☐No
☐Unknown
SIGNS/SYMPTOMS OF HUMAN ILLNESS
Date of illness onset(MM/DD/YYYY):__________ ☐Unknown
Approximate time of illness onset:
☐ Evening (6:00PM – 9:00PM)
☐ Early morning (12:00AM – 6:00AM)
☐ Night (9:00PM – 12:00AM
☐ Morning (6:00AM – 12:00 PM)
☐Unknown
☐ Afternoon (12:00PM – 6:00PM)
Date of illness recovery (MM/DD/YYYY):__________ ☐Unknown
Approximate time of illness recovery:
☐ Early morning (12:00AM – 6:00AM)
☐ Evening (6:00PM – 9:00PM)
☐ Morning (6:00AM – 12:00 PM)
☐ Night (9:00PM – 12:00AM
☐ Afternoon (12:00PM – 6:00PM)
☐Unknown
Length of time between illness onset and exposure:__________
☐ ≤3 hours ☐ >3 ≤ 12 hours ☐ >12 ≤ 24 hours ☐ >24 ≤48 hours ☐>48 hours ☐Unknown
Was the person still experiencing signs/symptoms at the time of the interview?
☐Yes ☐ No ☐ Unknown
Commonly Reported Sign/Symptom
Yes/No/Unknown
Rash/itchy skin
☐ Yes
☐No
☐Unknown
Vomiting
☐ Yes
☐No
☐Unknown
Diarrhea
☐ Yes
☐No
☐Unknown
Abdominal cramps
☐ Yes
☐No
☐Unknown
Cough
☐ Yes
☐No
☐Unknown
Headache
☐ Yes
☐No
☐Unknown
Malaise (general discomfort)
☐ Yes
☐No
☐Unknown
Fever
☐ Yes
☐No
☐Unknown
Tingling
☐ Yes
☐No
☐Unknown
Other signs/symptoms (Select all that apply): __________
Did any symptoms reoccur after multiple exposures?
☐Yes ☐ No ☐ Unknown
[If fish or shellfish] Were the signs/symptoms consistent with fish/shellfish poisoning?
☐Yes ☐ No ☐ Unknown
[If yes] Poisoning description (e.g., Ciguatera Fish Poisoning):__________
MEDICAL INFORMATION
HEALTHCARE SEEKING BEHAVIOR
Did the person receive first aid care from a non-medical provider? (e.g., park staff)
☐Yes ☐ No ☐ Unknown
Did the person visit a healthcare provider? (e.g., non-emergency, urgent care)
☐Yes ☐ No ☐ Unknown
Did the person go to an emergency department?
☐Yes ☐ No ☐ Unknown
Was a Poison Control Center contacted?
☐Yes ☐ No ☐ Unknown
HEALTH OUTCOMES
Was the person hospitalized?
☐Yes ☐ No ☐ Unknown
[If yes] How many days was the person hospitalized? __________
Did the person die?
☐Yes ☐ No ☐ Unknown
[If yes] Date of death (MM/DD/YYYY):__________

HEALTH INDICATORS
At the time of exposure did the person have any of the following health indicators?
Is this person considered immunocompromised?
☐Yes ☐ No ☐ Unknown
Chronic respiratory disease (e.g. asthma, COPD)
☐Yes ☐ No ☐ Unknown
Chronic skin disease (e.g. psoriasis, eczema)
☐Yes ☐ No ☐ Unknown
Chronic gastrointestinal disease (e.g. Crohn’s disease)
☐Yes ☐ No ☐ Unknown
Other chronic disease? __________
Was the person pregnant at the time of exposure?
☐Yes ☐ No ☐ Unknown
DIFFERENTIAL DIAGNOSIS AND CLINICAL TESTING
At the time of exposure, was the person taking medication that increased skin sensitivity to the sun (e.g., acne treatment, antibiotics)?
☐Yes ☐ No ☐ Unknown
At the time of exposure, did the person have an open wound, sores, or broken skin?
☐Yes ☐ No ☐ Unknown
Were other causes of illnesses investigated and ruled out?
☐Yes ☐ No ☐ Unknown
HUMAN LABORATORY TESTING
Were clinical specimens tested?
☐Yes ☐ No ☐ Unknown
[If yes]What type(s) of clinical testing were done to diagnose the illness or rule out other causes? (Select all that apply)
☐Imaging (e.g., x-ray, ultrasound, etc.)
☐Bloodwork
☐None
☐Fecal analysis
☐Other (specify) __________
☐Toxicological Analysis
☐Unknown
☐Urinalysis
HUMAN TESTING RESULTS
In the below table, please report any laboratory results of clinical specimens that were tested for algal/cyanobacterial toxins or species—more
extensive results may be attached to this report)
Clinical Specimen Number
1
2
3
Result Detected?
Sample Collection Date
(MM/DD/YYYY)
Specimen Type (e.g., blood)
Classification (e.g.,
Cyanobacteria)
Genus or toxin (e.g., Microcystis)
Species (e.g., aeruginosa)
Concentration(e.g., 20)
Unit (e.g., ppm)
Test type (e.g., ELISA)
HUMAN TESTING RESULTS REMARKS (Remarks should NOT include PII, CCI, other identifiers, webpage links, or additional location information.
Remarks should ONLY include information about the sample, test results, if whole blood what color tube top, or other relevant laboratory
information.):_____________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
GENERAL REMARKS (Remarks should NOT include any PII, CCI, other identifiers, webpage links, or lab/sample/testing information. Remarks should
only include relevant information not captured in the form.):______________________________________________________________________
________________________________________________________________________________________________________________________