New Jersey Department of Health

Vaccine Preventable Diseases Program

PO Box 369

Trenton, NJ 08625-0369

TETANUS SURVEILLANCE WORKSHEET	Case Status

Confirmed

Probable

Not a Case
Patient Name (Last, First)

Telephone No.

CDRSS #

E#

Street Address

City

Zip

County

Reporting Physician/Nurse/Hospital/Clinic/Lab

Address of Physician

Telephone No.

Country of Birth

Birth Date

__ __ / __ __ / __ __

(mm/dd/yy)	Age

__ __ __

(Unknown = 999)	Age Type

0-120 Years	0-2 Weeks

0-11 Months	0-28 Days

Age Unknown
Ethnicity

Hispanic

Not Hispanic

Unknown	Race

Native American/Alaskan Native	White

Asian/Pacific Islander	Other

African American	Unknown	Sex

Male

Female

Unknown
Event Date

__ __ / __ __ / __ __

(mm/dd/yy)	Event Type

Onset Date	Lab Test Date	Reported to State or MMWR Report Date

Diagnosis Type	Reported to County	Unknown
Reported

__ __ / __ __ / __ __

(mm/dd/yy)	Imported

Indigenous	Out of State

International	Unknown	Report Status

Confirmed	Not a Case

Probable	Unknown
HISTORY
Date / Year of Onset

__ __ / __ __ / __ __

(mm/dd/yy)	Occupation

History of Military Service (Active or Reserve)?

Yes No Unknown	Year of Entry into Military Service

__ __ __ __

(year)
Tetanus Toxoid (TT) History Prior to Tetanus Disease (Exclude Doses Received Since Acute Injury)

Never 1 Dose 2 Doses 3 Doses 4+ Doses Unknown	Years Since Last Dose

___ ___ (Unknown = 99)
CLINICAL DATA
Acute Wound Identified?

Yes Unknown

No	Date Wound Occurred

__ __ / __ __ / __ __

(mm/dd/yy)	Principal Anatomic Site

Head	Upper Extremity	Unknown

Trunk	Lower Extremity
Work Related?

Yes Unknown

No	Environment

Home	Farm/Yard	Other Outdoors

Other Indoors	Automobile	Unknown	Circumstances

Principal Wound Type

Puncture	Abrasion	Compound Fracture	Animal Bite	Unknown

Stellate Laceration	Avulsion	Other (e.g. with Cancer)	Insect Bite/Sting

Linear Laceration	Burn	Specify: ____________________	Dental

Crush	Frost Bite	Surgery	Tissue Necrosis
Wound Contaminated?

Yes Unknown

No	Depth of Wound?

< 1 cm Unknown

> 1 cm	Signs of Infection?

Yes Unknown

No	Devitalized, Ischemic or Denervated Tissue Present?

Yes No Unknown
MEDICAL CARE PRIOR TO ONSET
Was Medical Care Obtained for This Acute Injury?

Yes Unknown

No	Tetanus Toxoid (TT) or Td Administration Before Tetanus Onset?

Yes Unknown

No	If Yes, TT or Td Given How Soon after Injury?

< 6 Hours	5-9 Days	Unknown

7-23 Hours	10–14 Days

1-4 Days	15+ Days
Wound Debrided Before Tetanus Onset?

Yes Unknown

No	If Yes, Debrided How Soon after Injury?

< 6 Hours	1-4 Days	10 –14 Days	Unknown

7-23 Hours	5-9 Days	15+ Days
MEDICAL CARE PRIOR TO ONSET, CONTINUED
Tetanus Immune Globunin (TIG) Prophylaxis Received Before Tetanus Onset?

Yes Unknown

No	If Yes, TIG Given How Soon after Injury?

< 6 Hours	5-9 Days	Unknown

7-23 Hours	10-14 Days

1-4 Days	15+ Days	Dosage (Units)

__ __ __

(Unknown = 999)
Associated Condition (if no Acute Injury)?

Abscess	Gangrene	Cancer	Unknown

Ulcer	Cellulitis	Gingivitis

Blister	Other Infection	None	Describe Condition

Diabetes?

Yes Unknown

No	If Yes, Insulin-Dependent?

Yes Unknown

No	Parenteral Drug Abuse?

Yes Unknown

No	Describe Condition

CLINICAL COURSE
Type of Tetanus Disease

Generalized

Cephalic

Localized

Unknown	Diabetes?

Yes

No

Unknown	If Yes, TIG Given How Soon after Injury?

< 6 Hours	10-14 Days

7-23 Hours	15+ Days

1-4 Days	Unknown

5-9 Days	Dosage (Units)

__ __ __

(Unknown = 999)
Days Hospitalized

__ __ __

(Unknown = 999)	Days in ICU

__ __ __

(Unknown = 999)	Days Received Mechanical Ventilation

__ __ __

(Unknown = 999)	Outcome One Month After Onset?

Recovered

Convalescing

Died	If Died, Date Expired

__ __ / __ __ / __ __

(mm/dd/yy)
NEONATAL (< 28 DAYS OLD)
Mother’s Age in Years

___ ___

(Unknown = 99)	Mother’s Birthdate

__ __ / __ __ / __ __

(mm/dd/yy)	Date Mother’s Arrival in U.S.

__ __ / __ __ / __ __

(mm/dd/yy)	Mother’s Tetanus Toxoid (TT) History PRIOR to Child’s Disease (known disease only)

Never	3 Doses

1 Dose	4 Doses

2 Doses	Unknown	Years Since Mother’s Last Dose

__ __ __

(Unknown = 99)
Child’s Birthplace

Hospital	Other

Home	Unknown	Birth Attendant(s)

Physician	Unlicensed Midwife

Nurse	Ohter

Licensed Midwife	Unknown	Other Birth Attendant(s) (if not previously listed)

Other Comments?

Yes Unknown

No	Reporter’s Name

Title

Institution Name

Phone Number

( )	Date Reported

__ __ / __ __ / __ __

(mm/dd/yy)

Clinical Case Definition:

Acute onset of hypertonia and/or painful muscular contractions (usually of the muscles of the jaw and neck) and generalized muscle spasms without other apparent medical cause.
Case Classification:

Confirmed: A clinically compatible case, as reported by a health care professional.

TETANUS SURVEILLANCE WORKSHEET, Continued

IMM-22

JUL 12	Page 2 of 2 Pages.

JUL 12	Page 1 of 2 Pages.

IMM-22, Tetanus Surveillance Record

IMM-22, tetanus, surveillance, vaccine preventable diseases, VPDP, immunization, vaccine

ewhite

2008-09-29

NJDOH