Appendix 17-4 

Congenital Rubella Syndrome (CRS) Surveillance Worksheet 

CRS MMG 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 ם

_______________ ם ם

__ __ __ __ __ __ __ (__ __ __) ם ם

ם

 

physician PH clinic ADDRESS

nurse laboratory ZIP CODE 52831-5 

hospital other clinic PHONE

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 __ __ __ __ __ __ __ __ _____

 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 32624-9 ם Unknown

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

Age at Case Investigation 77998-3 _ Age Unit*OBX-6 for 77998-3 __ Reporting County 77967-8 ____ Reporting State 77966-0 ___

Date Reported __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ ___

 77995-9 month day year

Date First Reported to PHD 77970-2 month day year

National Reporting Jurisdiction

 77968-6 

Date First Reported to County 77972-8 __ __ __ __ __ __ __ __ (mm/dd/yyyy) Earliest Date Reported to State77973-6 __ __ __ __ __ __ __ _(mm/dd/yyyy) 

Case Class Status □Suspected םConfirmed םUnknown םProbable םNot a case Case Investigation Start Date __ __ __ __ __ __ __ __ (mm/dd/yyyy) 

CASE INVESTIGATION 

STATUS CODE INV109

Approved Deleted Notified Ready for review Reviewed Unknown

Closed In progress Other (specify) ________ Rejected Suspended

CLINICAL CASE APPRAISAL □ confirmed □ probable □ possible □ infection □ not CRS □ stillbirth 

 CASE DETECTION 

INV159 METHOD

Laboratory report Prenatal testing Provider reported Self-referral Confirmation Date__ __ __ __ __ __ __ __

 Other __________ Prison entry screening Routine physical Unknown INV162 month day year 

CASE INV161

CONFIRMATION

METHOD 

 Active surveillance Lab diagnosis No information given

Case/outbreak investigation Lab reporting Occupational disease surveillance

Clinical diagnosis Local/state specified Other (specify) _____________________________

Epi-linked Medical records review Provider certified 

INFANT HISTORY

Gestational Age (if case-patient <1 year of age) 18185-9 ___________ ____

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

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

(weeks) Birth State 80910-3 Birth Weight 8339-4

Birth Weight Unit OBX-6 for 8339-4 g=gram kg=kilogram oz=ounce lb=pound ___ Age at Diagnosis 63932-8 ___ Age Unit* at Diagnosis OBX-6 __

Hospitalized? 77974-4 Y=yes N=no U=unknown Hospital Admit Date 8656-1 month day year

Hospital Discharge Date 8649-6 month day year 

Hospital Stay Duration 0 – 998 999=unknown days 

 78033-8 

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 (mm/dd/yyyy) 

*UNITS OBX-6 a=year d=day mo=month w=week UNK=unknown

 Y N U Y N U Y N U

Cataract Hearing impairment Patent ductus arteriosus

Congenital glaucoma Low platelets Peripheral pulmonic stenosis

Congenital heart disease Meningoencephalitis Pigmentary retinopathy

Dermal erythropoiesis Microencephaly Purpura

Developmental delay or Mental retardation Neonatal jaundice Radiolucent bone disease

Enlarged liver Other (specify)_____________ Stenosis

Enlarged spleen Other congenital heart disease Unknown

 [Y=yes N=no U=unknown] INV920 

 

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PID-7

77979-3 77990-0 

77975-1

INV935

PID-10

 Mar 2019

INFANT TYPE OF 

COMPLICATIONS

67187-5
 

 

INFANT DEATH INFORMATION

Date of last evaluation by healthcare provider? __ __ __ __ __ __ __ __

 85734-2 month day year

Did infant d ie? 77978-5 Y=yes N=no U=unknown 

At the time of pregnancy cessation, what was the age of the fetus? 85719-3 (weeks ) Deceased Date __ __ __ __ __ __ __ __

PID-29 month day year

Death Certificate Primary Cause of Death INV337 ______________ Death Certificate Secondary Cause of Death INV338 ____________

MATERNAL HISTORY

Mother’s Birth Country MTH109_________ Mother’s Country of Residence NK1-4.6 _________ Mother’s Age at Delivery 85724-3 ___

Mother’s Age at Delivery Units† OBX-6 for 85724-3 ______ Length of time mother has been in the U.S. 85725-0 ___________ (years)

Did the mother attend a family planning clinic prior to conception? 85723-5 Y=yes N=no U=unknown

The number of children less than 18 years of age living in household during this pregnancy? 85722-7 ___________

 ______

Were any of the children living in the household immunized with rubella-containing vaccine? 85721-9 Y=yes N=no U=unknown

The number of children <18 years of age immunized with the rubella vaccine? 85720-1 

 †UNITS OBX_6 a=year d=day h=hour mo=month w=week min=minute s=second UNK=unknown

MATERNAL CLINICAL INFORMATION

Rash? 85733-4 Y=yes N=no U=unknown Rash Onset Date 85732-6 __ __ __ __ __ __ __ __

 month day year 

 __ __ __ __ __ __ __ __ 

________________________

Rash Duration 85731-8 (days)

Fever? 85730-0 Y=yes N=no U=unknown Fever Onset Date 85729-2 

 month day year Fever Duration 85728-4 (days)

Did the mother have lymphadenopathy during the time she was pregnant? 85727-6 Y=yes N=no U=unknown

Did the mother have arthralgia/arthritis during time she was pregnant? 85794-6 Y=yes N=no U=unknown

Did the mother have other clinical illnesses during the time she was pregnant? 85726-8 (specify)

Was prenatal care obtained for this pregnancy? 75204-8 Y=yes N=no U=unknown 

Date of first prenatal visit for this pregnancy? __ __ __ __ __ __ __ __

 

ם __ __ __ __ __ __ __ __

 75200-6 month day year

Prenatal Care Provider 85718-5 □public sector □private sector □unk

Did the mother have serological testing prior to this pregnancy? 85717-7 Y=yes N=no U=unknown

Mother's pre-pregnancy serological test date? 85674-0 month day year 

Pregnancy Outcome Live-CRS ם Other ם Unknown

 63893-2

What was the mother's pre-pregnancy serological test interpretation? 85675-7 susceptible immune unknown

Was there a rubella-like illness during this pregnancy? 85716-9 Y=yes N=no U=unknown 

Pregnancy month that rubella-like symptoms appeared? 85715-1 _____ Previous U.S. birth(s)? 85705-2 Y=yes N=no U=unknown

Was rubella physician-diagnosed? MTH124 Y=yes N=no U=unknown U.S. Birth Dates 85704-5 __ __ __ __ __ __ __ __ __ __ __ __ 

If rubella not diagnosed by physician, then by whom? MTH125 ____________________

___ 

Number of births delivered in U.S. 85703-7

Was rubella lab testing performed with this pregnancy? MTH123 Y=yes N=no U=unk Number of previous pregnancies? 75201-4 

Rubella serologically confirmed at time of illness? 85711-0 Y=yes N=no U=unknown Number of total live births? 75202-2

 

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EXPOSURE INFORMATION

Does the mother know where she might have been exposed to rubella? 85710-2 Y=yes N=no U=unknown 

Did the mother travel outside the U.S. during the first trimester of pregnancy? 85709-4 Y=yes N=no U=unknown

International 

Destination(s) of

Recent Travel 

82764-2

____________________________

____________________________

Date Left for Travel__ __ __ __ __ __ __ __ 

82752-7 month day year

Travel Return Date __ __ __ __ __ __ __ __ 

55209-1 month day year

____________________________

____________________________

Date Left for Travel__ __ __ __ __ __ __ __ 

82752-7 month day year

Travel Return Date __ __ __ __ __ __ __ __ 

55209-1 month day year

Import Status – US-Acquired INV516 1=import-linked case 2=imported virus case 3=endemic case 4=unknown source case 5=other 

Was the mother directly exposed to a confirmed case? 85708-6 Y=yes N=no U=unknown Exposure Date 85706-0 __ __ __ __ __ __ __ __

 month day year 

MOTHER’S RELATIONSHIP TO

CONFIRMED RUBELLA CASE Brother Friend Mother Other Spouse

Father Grandparent Neighbor Sister Unknown

Country of Exposure 77984-3 ____________________________________ State or Province of Exposure 77985-0 __________________________

County of Exposure 77987-6 _____________________________________ City of Exposure 77986-8 _________________________________________

CASE DISEASE 77982-7 

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 INV153 ______ Imported State INV154 ______ Imported County INV156 ________ Imported City INV155 __________

LABORATORY TESTING

VPD Lab Message Reference Laboratory LAB143 _________________ VPD Lab Message Patient Identifier LAB598 _____________________

VPD Lab Message Specimen Identifier LAB125 _____________ Lab testing done to confirm diagnosis? LAB630 Y=yes N=no U=unknown

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

Test

Type

INV290

Specimen 

from

85793-8

Date 

Specimen

Collected

68963-8 

 month day year

Date Specimen

Sent to CDC

85930-6 

month day year

Date 

Specimen

Analyzed 

45375-3 

month day year

Test Result INV291

Test ResultQuantitative LAB628

Result Units LAB115

Test Method 85069-3

Specimen 

Source

31208-2

Specimen 

Type 

66746-9

Performing

Lab Type 

 82771-7

mother

infant

unknown

IgM

IgM

(capture)

IgG EIA 

(acute)

IgG EIA

(conv)

culture

PCR

other

unknown

IFA

Ab latex

genotype

85707-8

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TEST RESULTS CODES

P=positive N=negative 

X=not done E=pending 

I=Indeterminate 

NS=no significant rise in titer

PS=significant rise in titer 

U=unknown

SPECIMEN TYPE CODES

1=entire throat 6=entire eye

2=intervertebral space 7=pharyngeal 

3=skin structure 8=other (specify) 

4=mouth region 9=unknown

5=lens of eye 10=nasal cavity

PERFORMING LABORATORY TYPE 

CODES 

1=CDC lab 5=public health lab

2=commercial lab 6=VPD testing lab 

3=hospital lab 8=other (specify) 

4=other clinical lab 9=unknown

GENOTYPE CODES

85690-6 1a 1F 2A 

1B 1g 2B 

1C 1H 2c 

1D 1I other 

1E 1J unknown 

SPECIMEN SOURCE 

2=blood 3=body fluid 4=BAL 8=cataract 9=CSF 11=DNA sample 15=NP aspirate 16=NP swab 17=NP washings 18=nucleic acid 

19=oral fluid 20=oral swab 21=plasma 22=RNA sample 23=saliva 25=serum 38=urine 40=viral isolate 41=other 42=unknown

 

VACCINATION HISTORY

Vaccinated (was the mother immunized with a rubella vaccine)? 85702-9 Y=yes N=no U=unknown

Number of vaccine doses the mother received on or after her first birthday? VAC129 0-6 99=unknown (doses)

Date of mother’s last vaccine dose against this disease prior to illness onset VAC142 __ __ __ __ __ __ __ __ (mm/dd/yyyy)

Was mother vaccinated as recommended by ACIP? VAC148 Y=yes N=no U=unknown If “no” select reason below:

Reason Not Vaccinated Per ACIP VAC149 

1 = religious exemption 6 = too young 11 = vaccine record incomplete/unavailable 16 = immigrant 

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 

5 = MD diagnosis of previous disease 10 = parent/patient forgot to vaccinate 15 = foreign visitor 

Source of mother’s vaccine information? 48766-0 1=mother 2=physician 3=school 4=IIS 8=other ____________________ 9=unknown 

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

_____

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VACCINE TYPE CODES

03=MMR (measles, mumps, rubella virus) 

04=M/R (measles & rubella virus) 

05=Measles (measles virus) OTH=other 

06=Rubella (rubella virus) 998=no vaccine administered 

07=Mumps (mumps virus) 999=unknown

38=Rubella/mumps (rubella & mumps virus) 

94=MMRV (measles, mumps, rubella, & varicella virus) 

VACCINE

MANUFACTURER 

CODES

MSD = Merck

OTH = other (specify)

UNK = unknown

VACCINE EVENT INFORMATION SOURCE CODES

 00=new immunization record 

 01=historical information, source unspecified 

 02=historical information, other provider 11=IIS record 

 05=historical information, other registry OTH=other (specify) 

 06=historical information, birth certificate UNK=unknown

 07=historical information, school record

 08=historical information, public agency

 09=historical information, patient or parent recall

 10=historical information, patient or parent written record 

Page 4 of 6 
CASE NOTIFICATION

CONDITION 

CODE OBR-31 10370 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 __ __ __ __ __ __ __ __

 month day year

Date Report First Electronically Submitted __ __ __ __ __ __ __ __

 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 NAME ____________________ (first)

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 __________________________

Current Industry 85078-4 _________________________________ Current Industry Standardized 85657-5 _______________________________

COMMENTS 77999-1

CLINICAL CASE DEFINITION ₸

SUSPECTED

An infant that does not meet the criteria for a probable or confirmed case but who has one of more of the following clinical findings: 

• cataracts or congenital glaucoma,

• congenital heart disease (most commonly patent ductus arteriosus or peripheral pulmonary artery stenosis),

• hearing impairment,

• pigmentary retinopathy,

• purpura,

• hepatosplenomegaly,

• jaundice,

• microcephaly,

• developmental delay,

• meningoencephalitis, OR

• radiolucent bone disease

PROBABLE

An infant without an alternative etiology that does not have laboratory confirmation of rubella infection but has at least two of the 

following§: 

o cataracts or congenital glaucoma,§

o congenital heart disease (most commonly patent ductus arteriosus or peripheral pulmonary artery stenosis),

o hearing impairment, OR

o pigmentary retinopathy;

OR 

An infant without an alternative etiology that does not have laboratory confirmation of rubella infection but has at least one or 

more of the following: 

o cataracts or congenital glaucoma,§ 

o congenital heart disease (most commonly patent ductus arteriosus or peripheral pulmonary artery stenosis), 

o hearing impairment, OR

o pigmentary retinopathy

AND one or more of the following: 

• purpura,

• hepatosplenomegaly,

• jaundice,

• microcephaly,

• developmental delay,

• meningoencephalitis, OR

• radiolucent bone disease

77994-2 OBR-7

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CONFIRMED

An infant with at least one symptom (listed above) that is clinically consistent with congenital rubella syndrome; and 

laboratory evidence of congenital rubella infection as demonstrated by: 

• isolation of rubella virus, 

OR

• detection of rubella-specific immunoglobulin M (IgM) antibody, 

OR

• infant rubella antibody level that persists at a higher level and for a longer period than expected from passive 

transfer of maternal antibody (i.e., rubella titer that does not drop at the expected rate of a twofold dilution per 

month), 

OR

● a specimen that is PCR positive for rubella virus.

OTHER CRITERIA

Infection only: 

An infant without any clinical symptoms or signs but with laboratory evidence of infection as demonstrated by: 

• isolation of rubella virus, 

OR

• detection of rubella-specific immunoglobulin M (IgM) antibody, 

OR

• infant rubella antibody level that persists at a higher level and for a longer period than expected from passive 

transfer of maternal antibody (i.e., rubella titer that does not drop at the expected rate of a twofold dilution per 

month), 

OR

• a specimen that is PCR positive for rubella virus.

§In probable cases, either or both of the eye-related findings (cataracts and congenital glaucoma) count as a single 

complication. In cases classified as infection only, if any compatible signs or symptoms (e.g., hearing loss) are identified 

later, the case is reclassified as confirmed.

₸

CSTE Position Statement 09-ID-61 at https://wwwn.cdc.gov/nndss/conditions/rubella-congenital-syndrome/case-definition/2010/

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