1. Are you reporting:

Drug Resistant S. pneumoniae Y ☐ ☐ ☐	

☐ ☐ ☐

☐☐-☐☐-☐☐☐☐

☐☐☐

☐	 ☐	 ☐	 ☐	

☐	 ☐	 ☐	

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N U 

Invasive Disease Y N U 

2. Date of Birth

MONTH DAY YEAR

3a. Age

3b. Is age in years/months/weeks/days?

years months weeks days

4. Sex Male Female Unknown

5. Race: (check all that apply)

American Indian / Alaska native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Other race (specify) ___________________________________

6. Ethnicity: is patient Hispanic or Latino? Y ☐ ☐ ☐

☐☐☐☐☐

☐ ☐ ☐

☐☐☐	

☐ ☐ ☐ _____________________________________

N U

7. State in which patient resided at time of diagnosis: ☐☐

8. Zip code at which patient

resided at time of diagnosis:

9a. Hospitalized? Y N U

9b. If hospitalized for this condition, how many days total was the patient 

hospitalized? (Include days from multiple hospitals if relevant)

NUMBER OF DAYS: 0-998; 999=UNKNOWN

10. Does this patient: (check all that apply)

Attend a day care* facility? Y N U

Facility Name

*DAY CARE IS DEFINED AS AS SUPERVISED GROUP OF 2 OR MORE 

 UNRELATED CHILDREN FOR >4 HOURS PER WEEK.

Reside in a long term care facility? Y ☐ ☐ ☐

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☐☐-☐☐-☐☐☐☐

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N U

Facility Name ____________________________________

11. Did patient die from this illness? Y N U

12. Onset Date

MONTH DAY YEAR

13. Type of infection caused by organism (check all that apply)

Bacteremia without focus

Cellulitis

Epiglottitis

Hemolytic uremic syndrome

Meningitis 

Osteomyelitis

Otitis media

Peritonitis

Pericarditis

Pneumonia

Septic arthritis

Other (specify) ______________________________________

14. Sterile site from which organism isolated: (check all that apply)

 ☐	 ☐	

☐	 ☐	

☐	 ☐	

☐	 ☐	

☐	 ☐	

) _____________________

 ☐☐-☐☐-☐☐☐☐

☐☐☐

☐	 ☐ ________________ ☐

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Blood Joint

CSF Bone

Pleural fluid Internal body site

Peritoneal fluid Muscle

Pericardial fluid Other normally sterile site

(specify

15a. Date first positive culture obtained 

DATE SPECIMEN TAKEN

MONTH DAY YEAR

15b. If known, indicate the serotype* 

If unknown, enter UNK above

* As of 4/7/17, the serotypes contained in the PCV7 - Prevnar 7 conjugate vaccine

are 4, 6B, 9V, 14, 18C, 19F, 23F; the serotypes contained in the PCV13 - Prevnar

13 conjugate vaccine are 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F; and the

serotypes contained the PPSV23 - Pneumovax polysaccharide vaccine are 1, 2, 3, 4,

5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, 33F.

16. Nonsterile sites from which organism isolated, if any:

Middle ear Sinus Other (specify)

17a. Does the patient have any underlying medical conditions

 or prior illness?

Y Yes. If yes fill out 17b.

N

17b. What underlying medical conditions does the patient have? 

(check all that apply)

Current smoker 

Multiple myeloma

Sickle cell anemia

Splenectomy/asplenia

Immunoglobulin deficiency

Immunosuppressive therapy (steroids, chemotherapy, radiation)

Leukemia

Hodgkin’s disease

DETACH HERE and transmit only lower portion if sent to CDC

NAME (Last, First) Hospital Record No.

Address (Street and No.) City County Zip Phone

Reporting Physician/Nurse/Hospital/Clinic/LabPhone Address Phone

Appendix 13

Streptococcus pneumoniae Surveillance Worksheet

(Invasive pneumococcal disease and drug-resistant S. pneumoniae)

Page 1 of 2

THROUGHOUT: Y=YES N=NO U=UNKNOWN

Streptococcus pneumoniae Surveillance Worksheet

CS276729

U Unknown. Skip to 18.
Detach Here

Asthma 

Emphysema/COPD

Systemic lupus erythematosus

Diabetes mellitus

Nephrotic syndrome

Renal failure/dialysis

HIV infection

AIDS (CD4 <200)

Cirrhosis/liver failure

Alcohol abuse 	☐

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	☐

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Cardiovascular disease (ASCVD) /CAD

Heart failure/CHF

CSF leak

Intraveinous drug use

Other malignancy (specify)

Organ/bone marrow transplant

Other prior illness (specify) _______________________________

18. Did patient receive POLYSACCHARIDE pneumococcal vaccine? Y ☐ N ☐ U ☐ If YES, please complete the list below.

☐☐-☐☐-☐☐☐☐ ☐	

☐	

☐	

☐☐-☐☐-☐☐☐☐

☐☐-☐☐-☐☐☐☐

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☐	

______________

______________

______________

DOSE DATE GIVEN (MONTH/DAY/YEAR) VACCINE NAME LOT NUMBER

1 Pneumovax 23 (Merck) Pnu-Imune23 (Wyeth) Other

2 Pneumovax 23 (Merck) Pnu-Imune23 (Wyeth) Other

3 Pneumovax 23 (Merck) Pnu-Imune23 (Wyeth) Other

19. Did patient receive CONJUGATE pneumococcal vaccine? Y ☐ N ☐ U ☐	If YES, please complete the list below.

DOSE DATE GIVEN (MONTH/DAY/YEAR) VACCINE NAME MANUFACTURER LOT NUMBER

1 ☐☐-☐☐-☐☐☐☐

☐☐-☐☐-☐☐☐☐

☐☐-☐☐-☐☐☐☐

☐☐-☐☐-☐☐☐☐

2

3

4

20. Resistance Testing Results

Oxacillin zone size: 

(valid 00–30) ☐☐mm Oxacillin interpretation:☐R < 20mm (possibly resistant) ☐S ≥20mm (susceptible) ☐	Unknown/not tested

SUSCEPTIBILITY METHOD CODES S/I/R RESULT CODES SIGN CODES MIC VALUE

A- AGAR: Agar dilution method

B- BROTH: Broth dilution

C- DISK: Disk diffusion (Kirby Bauer)

S- STRIP: Antimicrobial gradient strip (E-test)

S- SUSCEPTIBLE

B- INTERMEDIATE

C- RESISTANT

S- UNK. / NOT TESTED

Result indicates whether the microorganism is 

susceptible or not susceptible (intetrmediate or 

resistant) to the antimicrobial being tested

Indicate whether the MIC is <, >, ≤, ≥, = to the 

numerical MIC value in the last column

Valid range for data value 

0.000–999.999

MIC = minimum inhibitory concentration

21. ANTIMICROBIAL AGENT SUSCEPTIBILITY METHOD A/B/D/S S/I/R/U RESULT SIGN < / > / ≤ / ≥ / = MIC VALUE (e.g., 0.06 μg/ml)

Penicilin

Amoxicillin

Amoxicillin /clavulanic acid

Cefotaxime

Ceftriaxone

Cefuroxime

Vancomycin

Erythromycin

Azithromycin

Tetracycline

Levofloxacin

Sparfloxacin

Gatifloxacin

Moxifloxacinn

Trimethoprim /sulfamethoxazole

Clindamycin

Quinupristin/dalfopristin

Linazolid

Other: (list)

Submitted by:____________________________________ ( Phone _____ Date:☐☐-☐☐-☐☐☐☐ 	 	 MONTH DAY YEAR

VACCINATION HISTORY

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