New Jersey Department of Health

Vaccine Preventable Diseases Program

PO Box 369

Trenton, NJ 08625-0369

MUMPS SURVEILLANCE WORKSHEET	Case Status

Confirmed

Probable

Not a Case
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.

Birth Date

__ __ / __ __ / __ __

(mm/dd/yy)	Age

__ __ __

(Unknown = 999)	Age Type

0 0-120 Years	2 0-2 Weeks	9 Age Unknown

1 0-11 Months	3 0-28 Days
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
CLINICAL DATA	COMPLICATIONS
Clinical Profile	Course of Disease
Date of Onset	Duration of Symptoms (Days)	Symptoms	Y	N	U
Symptoms	Y	N	U
1	2	3	4	5	6	7
Fever (Max. __________ ( F)	Meningitis
Bilateral Parotid Swelling	Deafness
Unilateral Parotid Swelling	Orchitis
Parotid Tenderness	Encephalitis
Malaise	Death
Earache	///////////////	Other Complications

(If Yes, specify):

Pain in Jaw (Chewing/Eating)	///////////////
Arthralgia	///////////////
Hospitalized?

(If Yes, Days Hospitalized):

__ __ __

(0-998; 999 – Unknown)
Other (specify):

Headache
LABORATORY
Was Laboratory Testing for Mumps 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	X	Not Done

N	Negative	E	Pending

I	Indeterminate	U	Unknown	Specify Other Lab Method

VACCINE HISTORY
Vaccinated? (Received mumps-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	Vaccine Type Code (A=MMR, B=Mumps, 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 mumps?)

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 Other, specify 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:

Epi-Linked to Another Confirmed or Probable Case?

Yes No Unknown
STATE USE ONLY!	Date Surveillance Rec’d at State

__ __ / __ __ / __ __

(mm/dd/yy)	Date Reviewed at State

__ __ / __ __ / __ __

(mm/dd/yy)	Date Sent to CDC.

__ __ / __ __ / __ __

(mm/dd/yy)
CONTACT INFORMATION
Primary Contacts	Relationship To Patient	Exposure Date	Date of Birth	Sex	Telephone Number	Name of School/Work	Re-cent Ill.	Vacc	Dis.
Clinical Case Definition (1999):

An illness with acute onset of unilateral or bilateral tender, self-limited swelling of the parotid or other salivary gland, lasting = 2 days, and without other apparent cause.
Case Classification (1999):

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 confirmed or probable case.

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

MUMPS SURVEILLANCE WORKSHEET, Continued

IMM-21

JUL 12

IMM-21, Mumps Surveillance Record

IMM-21, mumps, surveillance, vaccine preventable diseases, VPDP, immunization, vaccine

ewhite

2007-01-25

NJDOH