New Jersey Department of Health

Vaccine Preventable Diseases Program

PO Box 369

Trenton, NJ 08625-0369

MEASLES SURVEILLANCE WORKSHEET	Case Status

Confirmed

Probable

Suspect
Patient Name (Last, First)

Telephone No.

CDRSS #

E#

Street Address

City

Zip

County

Reporting Source

Treating Physician

Address of Physician

Telephone No.

Dates Physician Saw

Name of Investigator

Name of Agency

Telephone No.

Hospital

Hospital Record Number

Hospital Address

Telephone No.

Country of Birth

Birth Date

__ __ / __ __ / __ __

(mm/dd/yy)	Age

__ __ __

(Unknown = 999)	Age Type

0 0-120 Years	2 0-2 Weeks

1 0-11 Months	3 0-28 Days

9 Age Unknown
Ethnicity

H Hispanic

N Not Hispanic

U Unknown	Race

N	Native American/Alaskan Native	W	White

A	Asian/Pacific Islander	O	Other

B	African American	U	Unknown	Sex

M	Male

F	Female

U	Unknown
Event Date

__ __ / __ __ / __ __

(mm/dd/yy)	Event Type

1 Onset Date	3 Lab Test Date	5 Reported to State or MMWR Report Date

2 Diagnosis Type	4 Reported to County	9 Unknown
Outbreak Associated

__ __ __

(Unknown = 999)	Reported

__ __ / __ __ / __ __

(mm/dd/yy)	Imported

1 Indigenous	3 Out of State

2 International	9 Unknown	Report Status

1 Confirmed	3 Not a Case

2 Probable	9 Unknown
CLINICAL DATA	COMPLICATIONS
Symptoms	Yes	No	Unknown	Symptoms	Yes	No	Unknown
Any Rash

If Yes, Date of Rash Onset:

__ __ / __ __ / __ __

(mm/dd/yy)

Rash Duration:

____ ____

(0-30; 99 = Unknown)	Otitis
Diarrhea
Pneumonia
Encephalitis
Thrombocytopenia
Rash Generalized	Death
Fever

If Recorded, Highest Measured Temperature

__ __ __ . __ Degrees F.

(36.0 – 110.0; 999=Unknown)	Other Complications

(If Yes, specify):

Cough	Hospitalized?

(If Yes, Days Hospitalized):

__ __ __

(0-998; 999 = Unknown)
Coryze
Conjunctivitis
LABORATORY
Was Laboratory Testing for Measles Done?

Yes No Unknown	Date IgM Specimen Taken

__ __ / __ __ / __ __

(mm/dd/yy)	Result

P	Positive	X	Not Done

E	Pending	I	Indeterminate

N	Negative	U	Unknown
Date IgG Acute Specimen Taken

__ __ / __ __ / __ __

(mm/dd/yy)	Date IgG Convalescent Specimen Taken

__ __ / __ __ / __ __

(mm/dd/yy)	Result

P	Significant Rise in IgG	X	Not Done

N	No Significant Rise in IgG	E	Pending

I	Indeterminate	U	Unknown
Other Lab Result

P	Positive	I	Indeterminate	E	Pending

N	Negative	X	Not Done	U	Unknown	Specify Other Lab Method

VACCINE HISTORY
Vaccinated? (Received measles-containing vaccine?)

Yes

No

Unknown	Number of doses received ON or AFTER 1st birthday:

If not vaccinated, what was the reason?

1 Religious Exemption	6 Under Age for Vaccination

2 Medical Contraindication	7 Parental Refusal

3 Philosophical Objection	8 Other

4 Lab Evidence of Previous Disease	9 Unknown

5 MD Diagnosis of Previous Disease
Vaccination Date

(MM/DD/YY)	Vaccine Type Code (A=MMR, B=Rubella, O=Other, U=Unknown)	Vaccine Manuf. Code

(M=Merck, O=Other, U=Unknown)	Lot Number
EPIDEMIOLOGIC
Date First Reported to a Health Dept.

__ __ / __ __ / __ __

(mm/dd/yy)	Date Case Investigation Started

__ __ / __ __ / __ __

(mm/dd/yy)	Outbreak Related?

Yes

No

Unknown	If Yes, Outbreak Name

Transmission Setting (Where did this case acquire measles?)

1 Day Care	6 Hospital Outpatient Clinic	11 Military

2 School	7 Home	12 Correctional Facility

3 Doctor’s Office	8 Work	13 Church

4 Hospital Ward	9 Unknown	14 International Travel

5 Hospital ER	10 College	15 Other	If Transmission Setting not among those listed and known, what was the transmission setting?

Were Age and Setting Verified? (Is age appropriate for setting, i.e., aged 49 years and in day care, etc.?

Yes No Unknown
Source of Exposure for Current Case (Enter State ID if source was an in-state case; enter Country if source was out of US; enter State if source was out-of-state):

Epi-Linked to Another Confirmed or Probable Case?

Yes Unknown

No	Is Case Traceable within 2 Generations to an International Import?

Yes Unknown

No
CONTACT INFORMATION (FOR STATISTICAL USE)
Mother’s Name

Telephone Number

Father’s Name

Telephone Number

ACTIVITY HISTORY FOR 18 DAYS BEFORE RASH ONSET AND 7 DAYS AFTER RASH ONSET
Day -18
Day -17
Day -16
Day -15
Day -14
Day -13
Day -12
Day -11
Day -10
Day -9
Day -8
Day -7
Day -6
Day -5
Day -4
Day -3
Day -2
Day -1
Day 0

(Rash Onset)
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7

Clinical Case Definition:

A generalized rash lasting > 3 days, a temperature > 101.0( F (> 38.3( C), and cough, coryza, or conjunctivitis.
Case Classification:

Suspected: any febrile illness accompanied by rash.

Probable: a case that meets the clinical case definition, has non-contributory or no serologic or virologic testing, and is not epidemiologically linked to a laboratory-confirmed case.

Confirmed: a case that is laboratory confirmed or that meets the clinical case definition and is epidemiologically linked to a confirmed case. A laboratory-confirmed case does not need to meet the clinical case definition.

MEASLES SURVEILLANCE WORKSHEET, Continued

IMM-11

JUL 12	Page 3 of 3 Pages.

JUL 12	Page 1 of 3 Pages.

IMM-11, Measles Surveillance Record

IMM-11, Measles, surveillance, vaccine preventable diseases, VPDP, immunization, vaccine, imm

ewhite

2008-09-10

NJDOH