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For Local Use Only VARICELLA DEATH INVESTIGATION WORKSHEET

Name Hospital Record Number LAST / FIRST / MIDDLE 

Current Reporting Physician/ Address NUMBER / STREET / APT. NUMBER Nurse/Hospital/

Clinic/Lab CITY / COUNTY / STATE ZIP CODE ADDRESS

Telephone: Home Work Telephone Number AREA CODE + 7 DIGITS AREA CODE + 7 DIGITS AREA CODE + 7 DIGITS

Detach here — Transmit only lower portion if sent to CDC

VARICELLA DEATH INVESTIGATION wORkSHEET

Reported by: State Case Number

 DEMOGRAPHIC DATA

 1. Date of Birth cc cc cccc MONTH DAY YEAR

 2. Current Age ccc (Unknown=999)

 3. Age Type c Years c Days c Hours

 c Months c Weeks c Unknown

 4. Current Sex c Male c Female c Unknown

 5. Ethnicity c Hispanic c Not Hispanic c Unknown

 6. Race c American Indian or Alaska Native

 c Asian c Black or African-American

 c Native Hawaiian or Other Pacific Islander

 c White c Other c Unknown

 7. Date of cc cc cccc Death MONTH DAY YEAR

 8. Country of Birth

 9. If not born in the U.S., case lived in U.S. for cc years.

10. Occupation

c Healthcare Worker 

c Teacher 

c Day Care Worker 

c Military Personnel 

c College Student

c Staff in Institutional Setting (e.g., Correctional Facility)

c Other (specify)

 MEDICAL HISTORY Y=Yes N=No U=Unknown

11. History of varicella before this c Y c N c U 19. Pre-existing conditions? c Y c N c U

infection? (Check all that apply)

ccc c Cancer Type: 12. If yes, age at infection? (Unknown=999)

c Transplant Recipient Organ: 13. Age Type c Years c Days c Hours c Immune Deficiency Type: c Months c Weeks c Unknown c Pregnancy 

14. History of serologic evidence c Y c N c U c Chronic Renal Failure 

 of immunity? c Diabetes Mellitus

15. Varicella Vaccine History c Vaccinated c Tuberculosis 

 c Not Vaccinated c Asthma 

 c Unknown c Chronic Lung Disease Specify: 

c Chronic Dermatolgic 16. If vaccinated Disorder Specify:

Date Dose 1 cc cc cccc c Chronic Autoimmune Disease (e.g., Lupus, MONTH DAY YEAR Reumatoid Arthritis) Specify: 

Date Dose 2 cc cc cccc Other Specify: c MONTH DAY YEAR

20. For a child <1 year old, did his/her c Y c N c U 17. If not vaccinated, was there a c Y c N c U mother have a history of varicella? contraindication to vaccination?

21. For a child <1 year old, did his/her c Y c N c U If yes, specify mother have a history of receipt 

18. Type of contraindication of varicella vaccine?

c Medical c Philosophical 22. Is this death the result of c Y c N c U

c Religious c Other congenital varicella infection?

23. In the month prior to rash onset, did the 

decedent take any of the following?

 Systemic Steroids c Y c N c U

 Name of Steroid: 

 Dose: mg/day Department of Health and Human Services cc Centers for Disease Control and Prevention Inhaled Steroids c Y c N c U

 Name of Steroid:

 Dose: cc mg/day 

 Other Systemic Medication c Y c N c U

 List medication 

 1) 3)

 2) 4)

continues

CDC 53.10B (E), Revised October 2012, CDC Adobe Acrobat 10.1, S508 Electronic Version, October 2012
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 ILLNESS PRIOR TO DEATH Y=Yes N=No U=Unknown

TREATMENT – MEDICATIONS (check all that apply) 24. Rash Onset cc cc cccc Date MONTH DAY YEAR 33. c Acyclovir

25. Was the rash generalized? c Y c N c U c Oral Dose cccc mg/day

26. When first noted, did rash lesions c Y c N c U

seem to cluster on one side of Start Date cc cc cccc

 the body? MONTH DAY YEAR

If “yes,” were lesions clustered c Y c N c U Duration ccc days

on one limited area of the body 

 nvolving no more than 3 dermatomes? c IV Dose cccc mg/day

 If “yes,” which area? (check all that apply)

 c Face/Head Start Date cc cc cccc MONTH DAY YEAR

 c Arms

 Duration ccc days c Legs

 c Trunk 34. c Famciclovir

 c Inside Mouth

 c Other (Specify) Dose cccc mg/day

27. Was the case hospitalized? c Y c N c U Start Date cc cc cccc MONTH DAY YEAR

Admission cc cc cccc Date MONTH DAY YEAR Duration ccc days

If obtainable, please attach a copy of the hospital 35. c Valacyclovir

 discharge summary. Dose cccc mg/day

COMPLICATIONS (check all that apply) Start Date cc cc cccc

28. c Secondary Infection MONTH DAY YEAR

 From c Strep Duration ccc days

 c Group A beta-hemolytic 36. c Varicella Zoster Immune Globulin (VZIG) c Other type

 c Unknown type Dose cccc U’s

 c Staph

 c MRSA Date cc cc cccc Admin’d Other (Specify) c MONTH DAY YEAR

 c Mixed 37. c Aspirin

 c Other (Specify) 38. c Non-Steroidal Anti-Inflammatory Drugs (i.e., ibuprofen)

 Type of Infection

 c Cellulitis

 c Osteomyelitis

 c Impetigo/Infected Skin Lesions

 c Necrotizing Fasciitis

 c Lymphadenitis

 c Toxic Shock Syndrome

 c Abscess

 c Sepsis/Septicemia

 c Septic Arthritis

 c Other (Specify)

29. c Pneumonia/Pneumonitis

 Etiology, if known

30. c Neurologic Complications

 c Cerebellitis/Ataxia

 c Encephalitis

 c Other (Specify)

31. c Reye’s Syndrome

32. c Other (Specify) continues

CDC 53.10B (E), Revised October 2012, CDC Adobe Acrobat 10.1, S508 Electronic Version, October 2012
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continues

LABORATORY Y=Yes N=No U=Unknown

39. Was laboratory testing done c Y c N c U 46. IgG performed? c Y c N c U

 for varicella? If “yes”: If “yes”:

 Type of IgG Test: 40. Direct fluorescent antibody (DFA) c Y c N c U

technique? c Whole Cell ELISA (specify manufacturer):

 Date of DFA cc cc cccc MONTH DAY YEAR c gp ELISA (specify manufacturer):

DFA Result c Positive c Pending c FAMA c Latex Bead Agglutination c Negative c Not Done c Other c Indeterminate c Unknown

Date of 41. PCR specimen? c Y c N c U cc cc cccc IgG-Acute MONTH DAY YEAR

Date of PCR cc cc cccc IgG-Acute c Positive c Pending Specimen MONTH DAY YEAR Result c Negative c Not Done

Source of PCR specimen: (check all that apply) c Indeterminate c Unknown

 c Vesicular Swab c Saliva Test Result Value c Scab c Blood

 c Tissue Culture c Urine Date of IgG- cc cc cccc Convalescent c Buccal Swab c Macular Scraping MONTH DAY YEAR

 c Other IgG-Conv. c Positive c Pending

Result c Negative c Not Done PCR Result c Varicella Positive c Not Done c Indeterminate c Unknown c Varicella Negative c Pending

 c Indeterminate c Test Result Value

 c Other 47. Were the clinical specimens sent c Y c N c U

Was the PCR specimen adequate c to CDC for genotyping (molecular typing)? Y c N c U If “yes”: (i.e., was it actin positive)?

42. Culture performed? c Y c N c U Date sent for cc cc cccc genotyping MONTH DAY YEAR

Date of 

Culture cc cc cccc 48. Was specimen sent for strain c Y c N c U

Specimen MONTH DAY YEAR (wild- or vaccine-type) identification?

Strain Type c Wild Type Strain Culture c Positive c Pending c Vaccine Type Strain Result c Negative c Not Done c Unknown c Indeterminate c Unknown

49. Any herpes simplex virus c Y c N c U

43. Was other laboratory testing c Y c N c U testing performed? If “yes”: done? If “yes”: Type of Test Specify c Tzanck smear

Other Test c Electron microscopy Date of cc cc cccc Other Test MONTH DAY YEAR

Date of cc cc cccc Test c Positive c Pending Other Test MONTH DAY YEAR Result c Negative c Unknown

Other Lab c Positive (results consistent with varicella infection) c Indeterminate Test Result c Negative

 c Indeterminate c Not Done

 c Pending c Unknown It can be difficult to distinguish varicella from dissemiTest Result Value nated herpes zoster (shingles). Serum or blood obtained 

from the decedent prior to or early in illness (i.e., weeks 

44. Serology performed? c Y c N c U before to ~4 days after rash onset) could be used to test for 

evidence of prior varicella infection, which could sometimes 45. IgM performed? c Y c N c U help distinguish these two conditions. If there is doubt If “yes”: whether the cause of death was related to varicella or to Type of c Capture ELISA c Unknown disseminated herpes zoster, an effort should be made as IgMTest c Indirect ELISA c Other soon as possible to determine whether any such blood 

Date IgM or serum specimens may be available. For instance, 

Specimen cc cc cccc serum specimens at hospital laboratories or a blood banks Taken MONTH DAY YEAR may be retained for many weeks.

IgM Test c Positive c Pending

Result c Negative c Not Done

 c Indeterminate c Unknown

Test Result Value

Unknown

CDC 53.10B (E), Revised October 2012, CDC Adobe Acrobat 10.1, S508 Electronic Version, October 2012
HOSPITAL DISCHARGE Y=Yes N=No U=Unknown

d.

50. Discharge summary information Y N U 

available? e.

51. Varicella included among Y N U f.

diagnoses? g.

52. Discharge Diagnoses 

 ICD-9 Code

h.

a.

i.

b. 

j.

c. 

POST-MORTEM EXAM Y=Yes N=No U=Unknown 

53. Post-mortem exam done? Y N 

54. Varicella included among diagnoses? Y N 

55. If evidence of varicella, significant findings related to 

varicella-zoster virus infection, by organ system: 

a. Organ 

Findings 

b. Organ 

Findings 

c. Organ 

Findings 

d. Organ 

Findings 

e. Organ 

Findings 

f. Other 

DEATH CERTIFICATE Y=Yes N=No U=Unknown

56. Death certificate available? Y N U

57. Varicella included as one Y N U

cause of death?

58. Cause of Death ICD-10 Code

a.

b.

 U

 U

c.

d.

Contributing Conditions ICD-10 Code

a.

b.

c.

d.

SOURCE Y=Yes N=No U=Unknown

59. Case had close contact with a Y N U 65. Transmission Athletics Hospital Outpatient

person with known or suspected Setting College Clinic

infection 10-21 days before rash onset? (Setting of

Exposure) Community Hospital Ward

60. Source had Shingles Varicella Unknown Correctional Facility International Travel

 Daycare Military 61. Current Age (Unknown=999) Doctor’s Office Place of Worship

62. Age Type Years Days Hours Home School

 Months Weeks Unknown Hospital ER Work

 Other Unknown

63. Varicella vaccine history of source Source vaccinated

 Source not vaccinated 

64. If not vaccinated, source had Y N U

contraindication to vaccination? 

If yes, specify 

66. If transmission was in the home 

 Transmission from family member by adoption 

 Transmission from family member biologically related 

67. Any international travel in the Y N U

4 weeks prior to illness? 

If yes, what dates? 

What country(ies)? 

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CDC 53.10B (E), Revised October 2012, CDC Adobe Acrobat 10.1, S508 Electronic Version, October 2012