Appendix 10-5

Mumps Surveillance Worksheet

 GENERIC MMG 

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

________________________ _____________________ _____________________________ __________________ ____________________

 (last) (first)

This information will not be sent to CDC

REPORTING SOURCE TYPE 48766-0 NAME ______________________ 

ם physician ם PH clinic ADDRESS ________________________

ם nurse ם laboratory ZIP CODE 52831-5 ________________

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

ם other source type ______________________________________ 

SUBJECT ADDRESS CITY PID-11.3 _________________

SUBJECT ADDRESS STATE PID-11.4 ________________

SUBJECT ADDRESS COUNTY PID-11.9 _____________

SUBJECT ADDRESS ZIP CODE PID-11.5 ___ ___ ___ ___ ___

LOCAL SUBJECT ID PID-3 _____________________

CASE INFORMATION

Date of Birth __ __ __ __ __ __ __ __

 PID-7 

 month day year

Sex M=male F=female U=unknown

PID-8

Ethnic Group H=Hispanic/Latino N=Not Hispanic/Latino O=Other _____ U=Unknown

PID-22

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

Country of Birth 78746-5 __________ Other Birth Place 21842-0 ____________ Country of Usual Residence 77983-5 ____________

Age at Case Investigation 77997-5 _ Age Unit* OBX-6 _ Reporting County 77967-8 _____________ Reporting State 77970-2 _____

Date Reported __ __ __ __ __ __ __ __

 77995-9 month day year

First Reported to PHD 77970-2 __ __ __ __ __ __ __ __

 month day year

National Reporting Jurisdiction ___ 

77968-6

EarliestDate Reported to County 77972-8 __ __ __ __ __ __ __ __

 month day year 

Earliest Date Reported to State 77973-6 __ __ __ __ __ __ __ __

 month day year

Case Class Status 77990-0 □Suspected םConfirmed םUnknown םProbable םNot a case

Case Investigation Start Date __ __ __ __ __ __ __ __

77979-3 

month day year

Case Investigation Status Code INV109 םapproved םclosed □ deleted םin progress םnotified ם other ____ ם rejected םreviewed םsuspended םunknown

Detection Method INV159 □ prenatal testing □ prison entry □ provider report □ routine physical □ self-referral □ other __________ □ unknown 

CLINICAL INFORMATION

Hospitalized? Y=yes N=no U=unknown

 77974-4

Hospital Admit Date __ __ __ __ __ __ __ __

8656-1 month day year

Hospital Discharge Date __ __ __ __ __ __ __ __ 

8649-6 month day year 

Hospital Stay Duration 0 – 998 

 78033-8 999=unknown days 

Illness Onset Date __ __ __ __ __ __ __ __

 11368-8 

 month day year

Illness End Date __ __ __ __ __ __ __ __

 77976-9 

 month day year

Illness Duration ______

77977-7

Illness Duration Units* _____

OBX-6 for 77977-7

Date of Diagnosis __ __ __ __ __ __ __ __

77975-1 month day year

Pregnancy Status 77996-7

Y=yes N=no U=unknown 

SIGNS and SYMPTOMS 56831-1 Y N U Y N U

Parotitis Fever

Sublingual salivary gland swelling Jaw pain

Submandibular salivary gland swelling Muscle pain

Headache Tiredness

Loss of appetite Other _____________

 Y=yes N=no U=unknown INV919

Parotitis INV301  bilateral  unilateral  other  unk

SALIVARY GLAND SWELLING 

 ONSET DATE __ __ __ __ __ __ __ __ 

 85931-4 month day year 

 

 DURATION ___________ (days) 

 85929-8 

COMPLICATIONS 67187-5 

 Y N U Y N U

Deafness Orchitis

Encephalitis Pancreatitis

Mastitis Other _________________

Meningitis Unknown

Oophoritis Death 77978-5 

 Y=yes N=no U=unknown INV920

Type of 

Deafness 

 INV307

□permanent □ temporary

□other ___________ □ unknown

Fever Onset Date 81266-9 

 __ __ __ __ __ __ __ __

 month day year

 Highest Temperature 

81265-1 ______ . ____ 

Deceased Date PID-29

 __ __ __ __ __ __ __ __

 month day year

Temperature Units 

 

◦

Cel 

◦

F 

 *UNITS OBX-6 a=year h=hour mo=month w=week d=day min=minute s=second OTH=other UNK=unknown

PID-10 32624-9

Mumps_V1.0_MMG_F_R1_20180504

OBX-6 for

81265-1

SEP 2021 Page 1 of 4
LABORATORY TESTING

VPD Lab Message Reference Laboratory

 LAB143 ________________________________

VPD Lab Message Patient Identifier

 LAB598 ____________________________________

VPD Lab Message Specimen Identifier

LAB 125 ____________________________

Was there laboratory testing done to confirm the diagnosis? LAB630 Y=Yes N=No U=Unknown

Was case laboratory confirmed? INV164 Y=yes N=no U=unknown Was a specimen sent to CDC for testing? 82314-6 Y=yes N=no U=unk

Test

Type

INV290

Test 

Result

INV291

Test Result 

Quantitative

LAB628

Result 

Units

LAB115

Specimen 

Source

(Type)

31208-2

Date Specimen

Collected

68963-8 

(mm/dd/yyyy)

 Date Specimen

Sent to CDC

85930-6 

(mm/dd/yyyy)

Specimen

Analyzed Date

OBX-19

(mm/dd/yyyy)

Performing

Laboratory 

Type

82771-7

IgM 1 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgM 2 __ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG 1

acute

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG

conv

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG

single

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

culture __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

genotype __ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

PCR 1 __ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

PCR 2 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

other __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

unspecified

serology

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

molecular 

typing

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

unknown __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Test Results Codes

P=positive N=negative 

X=not done I=Indeterminate 

E=pending O=other

NS=no significant rise in titer 

PS=significant rise in titer 

U=unknown

VT=vaccine type strain 

WT=wild type strain

Specimen Source Codes

1=bacterial isolate 8=cataract 15=NP aspirate 22=RNA 29=lavage 36=throat swab 

2=blood 9=CSF 16=NP swab 23=saliva 30=stool 37=tissue 

3=body fluid 10=crust 17=NP washing 24=scab 31=swab 38=urine

4=BAL 11=DNA 18=nucleic acid 25=serum 32=swab (skin lesion) 39=vesicle fluid 

5=buccal smear 12=lesion 19=oral fluid 26=skin lesion 33=swab (nasal sinus) 40=viral isolate 

6=buccal swab 13=macular scraping 20=oral swab 27=specimen 34=vesicular swab 41=other 

7=capillary blood 14=microbial isolate 21=plasma 28=lumg 35=swab (internal nose) 42=unknown 

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 9=unknown 

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IMPORTATION AND EXPOSURE INFORMATION

Imported Code 77982-7 1=Indigenous 2=international 3=in state, out of jurisdiction 4=out of state 5=imported, unable to detemine source 9=unknown 

Imported Country INV153 _______ Imported State INV154 ___ Imported County INV155 ________ Imported City INV156 ______________

IMPORT STATUS: Did onset occur within 12-25 days of entering the U.S. following any travel? INV293 Y=yes N=no U=unknown

IMPORT STATUS: US-Acquired INV516 1=import-linked case 2=imported virus case 3=endemic case 4=unknown source case 5=other ________ 

INTERNATIONAL 

DESTINATIONS 

OF RECENT 

TRAVEL 82764-2

_____________________

_____________________

Travel Return Date __ __ __ __ __ __ __ __ 

TRAVEL08 month day year

Length of time in the U.S since last

travel? DEM225 _____________________

_____________________

_____________________

Travel Return Date __ __ __ __ __ __ __ __ 

TRAVEL08 month day year

UNITS†LENGTH of TIME in the U.S. 

OBX-6 for DEM225 _____________________

†UNITS OBX-6 a=year h=hour mo=month w=week d=day min=minute s=second OTH=other UNK=unknown

Is this case epi-linked to another confirmed or probable case? INV217 Y=yes N=no U=unknown 

Outbreak related? Y=yes N=no U=unknown

77980-1

Outbreak Name __________

77981-9

Investigation Start Date __ __ __ __ __ __ __ __

77979-3 

 month day year

 

Country of Exposure _____

77984-3 

State/Province of Exposure _____

77985-0

County of Exposure ________

77987-6

City of Exposure________

77986-8

TRANSMISSION SETTING 81267-7 

1 = day care 6 = hospital outpatient 

2 = school 7 = home 11 = military 14 = international travel

3 󠆔= 󠆔doctor’s 󠆔office 󠆔 󠆔 󠆔 󠆔 󠆔 󠆔 󠆔8 󠆔= 󠆔other _______________________ 15 = community

4 = hospital ward 9 = unknown 12 = correctional facility 16 = work

5 = hospital ER 10 = college 13=church 17 = athletics

Transmission Mode 77989-2 ________________________________

Detection Method INV159

 routine physical exam  prenatal testing

 prison entry screening  other _____________________

 provider reported  self-referral  unknown 

Age & setting verified: does the age of the case match or make sense for the listed transmission setting? 85700-3 Y=yes N=no U=unknown

VACCINATION HISTORY

Vaccinated (has the case-patient ever received a vaccine against this disease)? VAC126 Y=yes N=no U=unknown 

Number of vaccine doses received on or after first birthday? VAC129 0–6; 99=unknown _____ (doses) Was case-patient vaccinated 

as recommended by the ACIP?

VAC148 Y=yes N=no U=unknown 

Number of vaccine doses received prior to illness onset? 82745-1 0–6; 99=unknown _____ (doses) 

Date of last vaccine dose prior to illness onset: VAC142 __ __ __ __ __ __ __ __ (mm/dd/yyyy) 

 

Vaccine

Type

30956-7 

Vaccination 

Date

 30952-6 

month day year

Vaccine

Manuf

30957-5

Vaccine

Lot Number

30959-1

Vaccine Expiration

Date VAC109 

month day year

National 

Drug 

Code

VAC153

Vaccination 

Record 

Identifier

VAC102

Vaccine Event 

Information 

Source

VAC147

Vaccine 

Dose 

Number

30973-2

_____

_____

_____

_____

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

_____

_____

_____

_____

____________

____________

____________

____________

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

_________

_________

_________

_________

___________

___________

___________

___________

________

________

________

________

____

____

____

____

VACCINE TYPE CODES

A=MMR R=rubella 

B=mumps virus vaccine RM=rubella/mumps

MR=M/R MM=MMRV

M=measles virus vaccine O=other 

U=unknown N=no vaccine administered 

VACCINE

MANUFACTURER 

CODES

M = Merck

 O = other

 U = unknown

VACCINE EVENT INFORMATION SOURCE CODES

00= new immunization record 08= historical information, public agency

01= historical information, source unidentified 09= historical information, patient/parent recall

02= historical information, other provider 10= historical information, patient/parent 

05= historical information, other registry written record

06= historical information, birth certificate UNK= unknown

07= historical information, school record OTH= other

REASON NOT VACCINATED PER ACIP VAC149 

1 = religious exemption 6 = too young 11 = vaccine record incomplete/unavailable 

2 = medical contraindication 7 = parent/patient refusal 12 = parent/patient report of previous disease ______

3 = philosophical objection 8 = other ______________________ 13 = parent/patient unaware of recommendation 

4 = lab evidence of previous disease 9 = unknown 14 = missed opportunity 16 = immigrant 

5 = MD diagnosis of previous disease 10 = parent/patient forgot to vaccinate 15 = foreign visitor 17 = vaccine not available 

VACCINE HISTORY COMMENTS VAC133

 

 Page 3 of 4
CASE NOTIFICATION

Condition Code 10180

OBR-31

Immediate National Notifiable Condition Y=yes N=no U=unknown

77965-2 

Legacy Case ID ___________

77997-5

State Case ID 77993-4 __ Local Record ID OBR-3 ___ Jurisdiction Code 77969-4 Binational Reporting Criteria 77988-4 ______________

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

 77994-2 month day year

Date Report First Electonically Submitted __ __ __ __ __ __ __ __

OBR-7 month day year

Date of Electronic Case Notification to CDC -- -- -- -- -- -- -- --

OBR-22 

 month day year

MMWR Week ____

 77991-8

MMWR Year ________________

 77992-6 

Notification Result Status OBR-25 Final results Record coming as correction Results cannot be obtained

Person Reporting to CDC __________________________ (first)

NAME 74549-7 _______________________________ (last)

Person Reporting to CDC Email 74547-1 _______________ @ ____________

Person Reporting to CDC Phone No. 74548-9 (__ __ __) __ __ __ __ __ __ __

Current Occupation 85658-3 _____________________________ Current Occupation Standardized 85659-1 (NIOCCS code) ___________

Current Industry 85078-4 __________________________________ Current Industry Standardized 85657-5 (NIOCCS code) ________________

COMMENTS 77999-1

CLINICAL CASE DEFINITION §

SUSPECTED

• ▪ Parotitis, acute salivary gland swelling, orchitis, or oophoritis unexplained by another more likely diagnosis, 

• OR

• ▪ A positive lab result with no mumps clinical symptoms (with or without epidemiological-linkage to a confirmed or probable 

case).

PROBABLE

• ▪ Acute parotitis or other salivary gland swelling lasting at least 2 days, or orchitis or oophoritis unexplained by another more 

likely diagnosis, in: 

o A person with a positive test for serum anti-mumps immunoglobulin M (IgM) antibody, OR

o A person with epidemiologic linkage to another probable or confirmed case or linkage to a group/community defined by 

public health during an outbreak of mumps.

CONFIRMED

▪ A positive mumps laboratory confirmation for mumps virus with reverse transcription polymerase chain reaction (RT-PCR) or 

culture in a patient with an acute illness characterized by any of the following: 

o Acute parotitis or other salivary gland swelling, lasting at least 2 days

o Aseptic meningitis

o Encephalitis

o Hearing loss

o Orchitis

o Oophoritis

o Mastitis

o Pancreatitis

§CSTE Position Statement 11-ID-18 at https://cdn.ymaws.com/www.cste.org/resource/resmgr/PS/11-ID-18.pdf

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