Appendix 14-1 

Suspected Polio Case Worksheet GENERIC MMG

REPORT CONTACT 

Name (Last, First) 74549-7 Initial Report Date 77995-9

Address City County 77967-8 State 

77966-0

Zip Code 52831-5 Phone 74548-9

Reporting Laboratory 48766-0 State 

PATIENT IDENTIFIERS 

Name (Last, First) Birth Date PID-7

City County PID-11.9 State PID-11.4 Occupation 

Age at Onset 

999 = Unknown 

Age Type 

 0 = 0 – 120 Years 

 1 = 0 – 11 Months 

 2 = 0 – 52 Weeks 

 3 = 0 – 28 Days 

 9 = Age Unknown 

Ethnicity PID-22 

 H = Hispanic 

N = Not Hispanic 

 U = Unknown

Race PID-10

N = Native American/Alaskan Native 

 A = Asian/Pacific Islander 

 B = African American 

 W = White 

 O = Other 32624-9

 U = Unknown

Sex PID-8

 M = Male 

F = Female 

 U = Unknown 

Date of Onset of First Symptoms 11368-8 

Month Day Year

Date of Onset of Paralysis

Month Day Year

CLINICAL COURSE 

Clinical Course

CSF RESULTS

Date 

Month Day Year

WBCs RBCs % Lymph % Polys Protein Glucose 

OUTCOME 

Date of 60-Day Follow-Up 

 Month Day Year 

Sites of Paralysis

1 = Spinal 

2 = Bulbar 

 3 = Spino-bulbar

Specific Sites 60-Day Residual 

1 = None 

 2 = Minor (any minor involvement) 

 3 = Significant (≤2 extremities, 

 major involvement) 

 4 = Severe (≥3 extremities and 

 respiratory involvement) 

 5 = Death 

 9 = Unknown

Date of Death PID-29

Month Day Year 

IMMUNIZATION HISTORY

TOPV within 30 Days Prior to Onset of Symptoms? 

Y = Yes 

 N = No 

 Date 

Month Day Year 

Lot Number ____________________

VACCINE DATE 1 DATE 2 DATE 3 

IPV-containing 

 Total Doses

 Ever Received Month Day Year 

Lot Number _____________________ 

Month Day Year 

Lot Number _______________________ 

 Month Day Year

Lot Number _________________

TOPV 

 Total Doses

 Ever received Month Day Year 

Lot Number _____________________ 

 Month Day Year 

Lot Number ______________________ 

 Month Day Year 

Lot Number __________________ 

BOPV 

 Total Doses 

 Ever Received Month Day Year

Lot Number _________________

Month Day Year

Lot Number ___________________

Month Day Year

Lot Number ________________ 

MOPV 

 Total Doses

 Ever Received Month Day Year

Lot Number _________________ 

Month Day Year

Lot Number ____________________

Month Day Year

Lot Number ________________ 

 Page 1 of 3 
Appendix 14-2 

INJECTIONS RECEIVED WITHIN 30 DAYS PRIOR TO ONSET OF ILLNESS

Date of First Injection 

Month Day Year 

 Substance of First Injection Describe

____________________

____________________

Site of First Injection

Substance of Injection 

 1 = Vaccine 

 2 = Antibiotic

3 = Other

Site of Injection 

1 = Left Deltoid

 2 = Right Deltoid

 3 = Left Thigh

4 = Right Thigh

5 = Left Gluteal

6 = Right Gluteal

Date of Second Injection 

Month Day Year

 Substance of Second Injection Describe

____________________

____________________

Site of Second Injection

Date of Third Injection

Month Day Year

Substance of Third Injection Describe

____________________

____________________

Site of Third Injection

Date of Fourth Injection 

Month Day Year 

 Substance of Fourth Injection Describe

____________________

____________________

Site of Fourth Injection 

Did Case/Household Member Travel 

To Endemic/Epidemic Area(s)? 

Y = Yes

N = No 

Location(s) of Exposure 

_________________

_________________

_________________

Date of Departure 

Month Day Year 

Date of Return 

Month Day Year

Was Case/Household Member 

Exposed to Person(s) from or 

Returning to Endemic Areas? 

Y = Yes

N = No 

_________________ 

_________________

_________________ Month Day Year Month Day Year

Did Case/Household Member have 

Contact with Known Case? 

Y = Yes

N = No 

__________________

__________________

__________________ Month Day Year Month Day Year

Did Case Have Contact 

With OPV Recipient? 

Y = Yes

 N = No 

 If “Yes”, Date of Contact with

 Household OPV Recipient 

Relation ________________ 

Month Day Year

 Age

 999 = Unknown 

Age Type

 Age Type 

 0 = 0 – 120 Years

 1 = 0 – 11 months

 2 = 0 – 52 Weeks

 3 = 0 – 28 Days 

 9 = Age Unknown

 If “Yes”, Date of Contact with 

 Nonhousehold OPV Recipient 

 Relation ________________ 

Month Day Year

Age

 999 = Unknown

Age Type 

Date Contact Received OPV

Month Day Year

 Dose Number ____________________ Lot Number ____________________

LABORATORY INFORMATION 

STATE OR LOCAL

LABORATORY

SERUM SPECIMENS SUBMITTED 

Laboratory Name _________________________________________ 

SERUM 1 

P1, P2, 

Or P3 

 1 = P1

2 = P2

3 = P3 

 Test 

1 = Neut.

2 = CF 

 Result 

 ______ 

 ______

 Date Drawn/Obtained 

Month Day Year

SERUM 1 

P1, P2, 

Or P3 

1 = P1

 2 = P2

3 = P3 

Test

1 = Neut.

2 = CF 

Result 

 ______ 

 ______

 Date Drawn/Obtained

Month Day Year

SPECIMENS SUBMITTED FOR ISOLATION 

SPECIMEN 1 

Results Laboratory

 Name

Specimen

Type 

 ________ ____________ ________ 

Date Drawn/Obtained

Month Day Year 

SPECIMEN 2 

Results Laboratory

Name

Specimen 

Type 

_______ ___________ _______

Date Drawn/Obtained 

Month Day Year

 Page 2 of 3 
 Appendix 14-3 

 LABORATORY INFORMATION (continued) 

CDC LABORATORY

 SERUM 1 

 P1, P2, 

 Or P3 

1 = P1

 2 = P2

 3 = P3 

 Test 

1 = Neut. 

2 = CF 

Result 

______ 

 ______ 

 Date Drawn/Obtained 

Month Day Year

 SERUM 1 

P1, P2, 

 Or P3 

 1 = P1 

 2 = P2 

3 = P3 

 Test

1 = Neut. 

2 = CF 

Result

 ______ 

 ______ 

Date Drawn/Obtained

Month Day Year

SPECIMEN 1 

Specimen

Type 

Results 

(Viral 

Type 

 _______ ______ 

 Strains 

 (Charac- 

 terization

Results) 

1 = O ligo - 

 nucleotide 

2 = G en om ic

 Sequencing 

3 = Polymerase 

 Chain 

 Reaction 

Date Received 

Month Day Year 

D a t e O b t ained 

Month Day Year

SPECIMEN 2 

Specimen 

Type 

Results 

 (Viral 

 Type) 

 _______ _______ 

 

Strains 

(Charac- 

 terization 

Results) 

1 = O lig o-

 

 nucleotide 

 2 = Genomic 

 Sequencing 

 3 = Polymerase 

 Chain 

 Reaction 

 Date Received 

Month Day Year 

 D a t e Obtained 

Month Day Year

EMG Conducted? 

1 = Yes 

 2 = No

EMG Results Date of EMG

Month Day Year 

Nerve Conduction? Nerve Results Date of Nerve Conduction 

Month Day Year

Immune Deficiency Diagnosed Prior to OPV Exposure? 

 1 = Yes 

 2 = No 

 3 = Other

 Diagnosis _______________________ 

 

Immune Studies Performed HIV Status 

 1 = Positive 

 2 = Negative 

 9 = Unknown

ADDITIONAL COMMENTS 

77999-1 

Page 3 of 3