Appendix 9-3

 Meningococcal Disease Surveillance Worksheet 

JUN 2019 Page 1 of 5

NAME ADDRESS (Street and No.) Phone Hospital Record No. 

________________________ _____________________ _____________________________ __________________ ____________________

 (last) (first)

This information will not be sent to CDC

REPORTING SOURCE TYPE NAME _________________________ 

ם physician ם PH clinic ADDRESS _______________________

ם nurse ם laboratory ZIP CODE _______________________

ם hospital ם other clinic PHONE (__ __ __) __ __ __ __ __ __ __

ם other source type _______________________________________ 

SUBJECT ADDRESS CITY _____________________________

SUBJECT ADDRESS STATE ___________________________________

SUBJECT ADDRESS COUNTY __________________________

SUBJECT ADDRESS ZIP CODE __ __ __ __ __ 

LOCAL SUBJECT ID ____________________________ 

CASE INFORMATION 

Date of Birth __ __ __ __ __ __ __ __ 

 month day year Country of Birth __________ Other Birth Place ______ Country of Usual Residence _____

Ethnic Group H=Hispanic or Latino N=Not Hispanic/Latino O=Other _____________ U=Unknown Sex M=male F=female U=unknown

Race םAmerican Indian/Alaskan Native םAsian םBlack/African American םNative Hawaiian/Pacific Islander םWhite םNot asked ם Refused to answer םOther ם Unknown

Age at Case Investigation _________ Age Unit* _______ Reporting County _____________ Reporting State _________

Date Reported __ __ __ __ __ __ __ __

 month day year

Date First Reported to PHD __ __ __ __ __ __ __ __ 

 month day year National Reporting Jurisdiction _______

Earliest Date Reported to County __ __ __ __ __ __ __ __ (mm/dd/yyyy) Earliest Date Reported to State __ __ __ __ __ __ __ __ (mm/dd/yyyy)

Case Class Status Suspected Probable Confirmed Unknown Not a case

CASE INVESTIGATION 

STATUS CODE 

 ם approved םclosed םdeleted םin progress םnotified ם___ other ____________ 

 ם ready for review ם rejected ם reviewed ם suspended םunknown

Case Report Form Status Chart unavailable after 3 requests Complete Edited & correct Incomplete Quality assurance review change

ABCs State ID ______ Is this a secondary case? Y=yes N=no U=unknown Case Investigation Start Date __ __ __ __ __ __ __ __ 

 month day year

CLINICAL INFORMATION

 Illness Onset Date __ __ __ __ __ __ __ __ month day yearIllness End Date __ __ __ __ __ __ __ __ month day year Illness Duration _____ Duration Units* _______

 Illness Onset Age Illness Onset Age Units* Date of Diagnosis __ __ __ __ __ __ __ __ (mm/dd/yyyy) 

Hospitalized? Y=yes N=no U=unknown Hospital Admission Date __ __ __ __ __ __ __ __ 

 month day year

Hospital Discharge Date __ __ __ __ __ __ __ __

 month day year

Duration of Hospital Stay 0 – 998 999=unknown _____ (days) Epi-linked to a laboratory-confirmed case? Y=yes N=no U=unknown

Does this patient attend a day care facility? Y=yes N=no U=unknown Facility Name ________________________________

Does this patient reside in a long-term care facility? Y=yes N=no U=unknown Facility Name ______________________________

Was the patient taking eculizumab/Soliris at the time of disease onset? Y=yes N=no U=unknown

*UNITS a=year d=day h=hour min=minute mo=month s=second wk=week UNK=unknown

SYMPTOMS

DURING 

COURSE OF 

ILLNESS

 Y N U Y N U Y N U Y N U Y N U 

Chills Fever Gastrointestinal illness Pneumonia Vomiting

Cough Headache Muscle pain Rash Unknown

Diarrhea Nausea Photophobia Stiff neck Other ___

[Y=yes N=no U=unknown]

BACTERIAL INFECTION SYNDROME (types of infection caused by organism):

Abortion with sepsis Cellulitis Epiglottitis Osteomyelitis Pneumonia

Abscess (not skin) Chorioamnionitis Hemolytic Uremic Syndrome Other (specify) Puerperal septicemia

Asymptomatic bacteremia Empyema Infective arthritis Otitis media Septic shock

Bacteremia without focus Endocarditis Meningitis Pericarditis Staphylococcal Toxic Shock

Bacterial septicemia Endometritis Necrotizing fasciitis Peritonitis Unknown
Did patient have any underlying causes or prior illnesses? Y=yes N=no U=unknown If “yes” select below:

Underlying Conditions Y N U Y N U Y N U Y N U 

AIDS Congestive heart failure Immunoglobulin deficiency Parkinson’s disease

Alcohol abuse Connective tissue disorder Immunosuppressive therapy Peptic ulcer

Asthma Coronary arteriosclerosis Intravenous drug user Peripheral neuropathy

Blood cancer Corticosteroids Kidney disease Peripheral vascular disease

Bone marrow transplant CSF leak Leukemia Premature birth

Broken skin Current chronic dialysis Missing spleen Renal failure/dialysis

Cancer Current smoker Multiple myeloma Seizure disorder

Cancer treatment Deaf/profound hearing loss Multiple sclerosis Sickle cell trait

Cerebrovascular accident Dementia Myocardial infarction Solid organ malignancy

Chronic hepatitis C Diabetes mellitus Nephrotic syndrome Solid organ transplant

Chronic respiratory disease Emphysema/COPD Neuromuscular disorder Splenectomy/asplenia

Cirrhosis/liver failure Former smoker None Systemic lupus erythematosus

Cochlear prosthesis Hodgkin’s disease Obesity Trouble swallowing

Complement deficiency HIV infection Paralysis Unknown

[Y=yes N=no U=unknown] Other (specify) __________________________________________________________

Is patient (15-24 years only) currently attending college? Y=yes N=no U=unknown Name of College ______________ 

GRADE IN 

SCHOOL

Senior

Graduate student Sophomore

Junior Unknown

Other (specify) ___________________

COLLEGE 

LIVING 

SITUATION

Dormitory On campus private room

Off campus at home Other ________________

Off campus private housing Unknown

Off campus house/apartment with roommate(s)

Weight at Diagnosis Weight 

Units 

 gram kilogram

 ounce pound Height at Diagnosis Height 

Units 

 centimeter 

 Inch

Recurrent disease with same pathogen? Y=yes N=no U=unknown State ID of 1st occurrence for this pathogen _____________

Pregnancy status at time of first positive culture Not pregnant nor postpartum Currently Pregnant Postpartum Unknown

If pregnant or postpartum, what was the outcome of the fetus? (select below) Subject died? ? yes no unknown

Live birth/neonatal death Survived, clinical infection Still pregnant Unknown

Induced abortion Survived, no apparent illness Abortion/still birth

Deceased Date __ __ __ __ __ __ __ __

 mm/dd/yyyy 

If patient <1 month of age: ▪ Gestational age (weeks) ▪ Birth weight _______ Birth 

Weight 

Units 

Gram Kilogram

Was the patient ho Ounce Pound meless at time of symptom onset? yes no unknown 

RESIDENCE LOCATION AT 

TIME OF INITIAL CULTURE

 םHome םNon-medical ward םCollege dorm םHomeless םIncarcerated 

םLong-term Care םLong-term acute care םOther _____________________ םUnknown

Has patient had sex with a male in the past 12 months? yes no unknown did not ask refused to answer

In the 3 months prior to onset of symptoms, how many male sex partners has the patient had? 

Has patient had sex with a female in the past 12 months? yes no unknown did not ask refused to answer

HIV 

STATUS

HIV positive

HIV negative

Unknown

TYPE OF

INSURANCE

Incarcerated Managed care (unspecified) MEDICAID Uninsured

Indian Health Service Other (specify) _____________ MEDICARE Unknown

Managed care Military/VA Private health

IMPORTATION AND EXPOSURE INFORMATION

CASE DISEASE 

IMPORTED CODE

Indigenous In state, out of jurisdiction Unknown

International Out of state Yes, imported, but not able to determine source state/country

Imported Country ____________ Imported State __________ Imported County ______________ Imported City ___________________

Country of Exposure _______________________________________ State or Province of Exposure _______________________________

County of Exposure _________________________________________ City of Exposure ____________________________________________

Outbreak related? Y=yes N=no U=unknown Outbreak Name ___________ Transmission Mode __ __ __ __ __ __ __ __ __

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Freshman
LABORATORY INFORMATION

VPD Lab Message Reference Laboratory __________________________________________VPD Lab Message Patient Identifier

 __________________________________________

VPD Lab Message Specimen Identifier

 __________________________________________

BACTERIAL SPECIES

ISOLATED

 Neisseria meningitidis Haemophilus influenzae Group B streptococcus Other (specify)

 Listeria monocytogenes Group A streptococcus Streptococcus pneumoniae 

Was Laboratory Testing Done to Confirm the Diagnosis? Y=Yes N=No U=Unknown

Was Case Laboratory Confirmed? Y=yes N=no U=unknown Was a Specimen Sent to CDC for Testing? Y=yes N=no U=unknown

Test

Type

Test

Result

Date 

Specimen

Collected

 mm dd yyyy

Test Result Quantitative

Result Units

Test 

Method

Test Manufacturer

Date 

Specimen

Sent to CDC

mm dd yyyy

Specimen 

Type Serogroup

Serogroup Method

Lab Accession Number

Performing

Laboratory 

Name 

Performing Lab Type

 

 

 

 

 

 

 

 

LABORATORY TESTING CODES

LAB TEST TYPE

 1=antigen 

 2=susceptibility 

 3=culture 

 4=genotyping 

 5=Gram stain 

 6=immunohistochemistry 

 7=latex agglutination 

 8=other (specify)

 9=unknown

10=PCR

11=serotyping

12=species confirmation

13=genome sequencing

Specimen Type 

1=amniotic fluid 13=liver 25=pleural fluid

2=BAL 14=lung 26=purpuric lesions

3=blood 15=lymph node 27=respiratory secretion 

4=bone 16=middle ear 28=serum

5=brain 17=muscle/fascia/tendon 29=sinus

6=CSF 18=NP swab 30=spleen

7=heart 19=oropharyngeal swab 31=sputum 

8=other (specify) 20=ovary 32=stool

9=unknown 21=pancreas 33=tracheal aspirate

10=internal body site 22=pericardial fluid 34=urine

11=joint 23=peritoneal fluid 35=vascular tissue 

12=kidney 24=placenta 36=vitreous

 37=wound

SEROGROUP METHOD

1=culture 2=PCR 3=slide agglutination 8=other 9=unknown

SEROGROUP

1=A 3=C 5=X 7=not-groupable 9=unknown

2=B 4=W135 6=Y 8=other (specify) 10=not tested

TEST RESULT INTERPRETATION

P=positive N=negative I=indeterminate E=pending 

S=significant rise in titer NS=no significant rise in titer

Q=equivocal X=not done O=other U=unknown

V=vaccine type strain W=wild type strain

PERFORMING LABORATORY TYPE

1=CDC lab 2=commercial lab 3=hospital lab 4=other clinical lab 

5=public health lab 6=VPD testing lab 8=other (specify) 9=unknown

LAB TEST METHOD

A=Antigen Card B=BD Directigen BC=BCID Blood culture panel

BCT=Blood culture MA=MALDI Biotyper 

ME=meningitis/encephalitis panel 

O=Other (specify) W=Wellcogen Rapid Antigen U=Unknown

LABORATORY SUSCEPTIBILITY TESTING

Was any susceptibility data available? Y=yes N=no U=unknown 

Antimicrobial Susceptibility Test Type Test Method Susceptibility Interpretation Performing 

Laboratory Type

SUSCEPTIBILITY TEST METHOD CODES

 A=AGAR Agar dilution method S=STRIP Gradient strip (E-test)

 B=BROTH Broth dilution method I=Automated testing instrument 

 C=DISK DISK dilution (Kirby Bauer) G=whole genome sequencing

SUSCEPTIBILITY RESULT CODES

S=SUSCEPTIBLE I=INTERMEDIATE N=NOT DONE

R=RESISTANT U=UNKNOWN

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VACCINATION HISTORY INFORMATION

Vaccinated (has the case-patient ever received a vaccine against this disease)? Y=yes N=no U=unknown 

Number of vaccine doses against this disease received prior to illness onset 0–6 99=unk (doses)

Date of last vaccine dose against this disease prior to illness onset? __ __ __ __ __ __ __ __ (mm/dd/yyyy)

Was case-patient vaccinated as recommended by the ACIP? Y=yes N=no U=unknown 

Vaccine

Type

Vaccination 

Date 

month day year

Vaccine

Manuf

Vaccine

Lot 

Number

National 

Drug 

Code

Vaccine 

Expiration 

Date

month day year 

Vaccine 

Name 

Vaccine 

Event 

Information 

Source

Vaccination 

Record 

Identifier

Age† Age 

UnitsŦ

Vaccine 

Dose 

Number

______

______

______

______

 ______

 ______

______

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_ _ _ _ _ _ _ _

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VACCINE TYPE CODES 32=MPSV4 (Menomune) 162=men. B, recombinant 

103=men. C conjugate (Trumenba) 

108=men. ACWY,unspecified 163=men. B, OMV(Bexsero) 

114=MCV4P (Menactra) PHC1560=type not specified 

136=MCV4O (Menveo) OTH=other (specify)

147=MCV4, unspecified 999=unknown 

148=men. C/Y-HIB PRP (MenHibRix 

VACCINE MANUFACTURER 

CODES

 BHA=Baxter Healthcare PFR=Pfizer 

MSD=Merck & Co., Inc. PMC=Sanofi Pasteur

NOV=Novartis SKB=GlaxoSmithKline

OTH=other (specify) WAL=Wyeth UNK=unknown

 VACCINE EVENT INFORMATION SOURCE 

CODES

1=Birth certificate 8=Other

2=IIS 9=Unknown

3=Medical record 10=Patient or parent’s written record

4=New immunization record 11=Primary care provider 

5=Other provider 12=Public agency

6=Other registry 13=School record 

7=Patient or parent’s recall 14=Source unspecified 

†Age at 

vaccination

₸Age Units

a=year 

d=day

mo=month 

wk=week

OTH=other 

UNK=unknown

Reason not Vaccinated per ACIP 

1 = religious exemption 5 = MD diagnosis of previous disease 9 = unknown 13 = parent/patient unaware of recommendation 

2 = medical contraindication 6 = too young 10 = parent/patient forgot to vaccinate 14 = missed opportunity

3 = philosophical objection 7 = parent/patient refusal 11 = vaccine record incomplete/unavailable 15 = foreign visitor 

4 = lab evidence of previous disease 8 = other _______________ 12 = parent/patient report of previous disease 16 = immigrant 

Vaccine History Comments 

CASE NOTIFICATION

CONDITION 

CODE 10150 Immediate National Notifiable Condition Y=yes N=no U=unknown Legacy Case ID ______

State Case ID _____ Local Record ID _______ Jurisdiction Code ____ Binational Reporting Criteria ___ ___ ___ ___ ___ ___ ___

Date First Verbal Notification to CDC __ __ __ __ __ __ __ __

 month day year

Date Notification First Electonically Submitted __ __ __ __ __ __ __ __

 month day year

Date of Electronic Case (this version) Notification to CDC __ __ __ __ __ __ __ __

 month day year

MMWR Week ____ MMWR Year ______ 

Notification Result Status F = Final C = Record is a correction X = Results cannot be obtained 

Person Reporting to CDC Name ____________________ (first)

 ________________________________ (last) 

Person Reporting to CDC Email ________________ @ ______________

Person Reporting to CDC Phone Number (__ __ __) __ __ __ __ __ __ __

Current Occupation ______________________________________ Current Occupation Standardized _______________________________

Current Industry _________________________________________ Current Industry Standardized __________________________________

Comments 

Page 4 of 5
CLINICAL CASE DEFINITION§

SUSPECTED

● Clinical purpura fulminans in the absence of a positive blood culture; or

● Gram-negative diplococci, not yet identified, isolated from a normally sterile body site (e.g., blood or CSF)

PROBABLE

● Detection of N. meningitidis antigen

In formalin-fixed tissue by immunohistochemistry (IHC); or

In CSF by latex agglutination

CONFIRMED

• Detection of N. meningitidis-specific nucleic acid in a specimen obtained from a normally sterile body site (e.g., blood or 

CSF), using a validated polymerase chain reaction (PCR) assay; or 

● Isolation of N. meningitidis

From a normally sterile body site (e.g., blood or CSF, or less commonly, synovial, pleural, or pericardial fluid); or

From purpuric lesions.

 §//wwwn.cdc.gov/nndss/conditions/meningococcal-disease/case-definition/2015/

 

 

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