Appendix 11-4 

Pertussis Surveillance Worksheet 

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

________________________ ___________________ _________________________________ __________________ ____________________

 (last) (first)

This information will not be sent to CDC

REPORTING SOURCE TYPE NAME _______________________ 

ם physician ם PH clinic ADDRESS _______________________

ם nurse ם laboratory ZIP CODE ______________________ 

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

ם other source type _______________________________________ 

SUBJECT ADDRESS CITY ____________________________

SUBJECT ADDRESS STATE __________________________________

SUBJECT ADDRESS COUNTY __ __ __ __ __

SUBJECT ADDRESS ZIP CODE _________________________ 

LOCAL SUBJECT ID ___________________________________ 

CASE INFORMATION

Date of Birth __ __ __ __ __ __ __ __ 

 month day year Country of Birth _____ Other Birth Place _____ Country of Usual Residence _______

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

Ethnic Group H=Hispanic or Latino N=Not Hispanic/Latino O=Other __________ U=Unknown Sex M=male F=female U=unknown

Age at Case Investigation _________ Age Unit* _______ Reporting County __________ Reporting State ________

Date Reported __ __ __ __ __ __ __ __

 month day year

Date First Reported to PHD __ __ __ __ __ __ __ __

 month day year National Reporting Jurisdiction ______

Earliest Date Reported to County __ __ __ __ __ __ __ __ (mm/dd/yyyy) Earliest Date Reported to State __ __ __ __ __ __ __ __ (mm/dd/yyyy)

Case Class Status םSuspected ם Probable ם Confirmed ם Unknown ם Not a case Case Investigation Start Date __ __ __ __ __ __ __ __ 

 month day year

Case Detection Method ם prenatal testing ם prison entry ם provider report ם routine physical ם self-referral □ other ___________ □ unknown 

Case Investigation Status Code םapproved םclosed םdeleted םin progress םnotified ם other______ ם rejected ם reviewed םsuspended םunknown

CLINICAL INFORMATION

 Illness Onset Date __ __ __ __ __ __ __ __

 month day year

Illness End Date __ __ __ __ __ __ __ __

 month day year Illness Duration ___ Duration Units* ______

Hospitalized? Y=yes N=no U=unknown Hospital Admission Date __ __ __ __ __ __ __ __ 

 month day year

Hospital Discharge Date __ __ __ __ __ __ __ __

 month day year

Duration of Hospital Stay 0 – 998 _____ 

999=unknown (days) 

Date of Diagnosis __ __ __ __ __ __ __ __

 month day year

Pregnancy Status Y=yes N=no U=unknown

SIGNS AND SYMPTOMS 

 Y N U Y N U

Apnea Post-tussive vomiting

Cough Whoop

Cyanosis Other (specify) _______

Paroxysmal cough ______________________

 Y=yes N=no U=unknown 

 COMPLICATIONS

 Y N U

Encephalopathy

Seizures

Other ___________________

 Y=yes N=no U=unknown 

Cough Onset Date __ __ __ __ __ __ __ __ (mm/dd/yyyy) 

 month day year Age at Cough Onset Age Unit* _________

Total Cough Duration ------------- Was there a cough at patient’s final interview? Y=yes N=no U=unknown

Date of Final Interview __ __ __ __ __ __ __ __ 

 month day year Subject died? Y=yes N=no U=unknown Deceased Date __ __ __ __ __ __ __ __ month day year

Chest X-Ray for Pneumonia P=positive N=negative X=not done U=unknown Were antibiotics given? Y=yes N=no U=unknown 

*UNITS a=year d=day h=hour min=minute mo=month s=second wk=week UNK=unknown

AUG 2020 Page 1 of 5 

 (days)
TREATMENT

First Antibiotic Received Date Treatment Initiated __ __ __ __ __ __ __ __

 month day year

Treatment Duration (days) 

ANTIBIOTIC(S) GIVEN

 1 = amoxicillin 2 = amoxicillin-potassium clavulanate combination 3 = ampicillin 4 = azithromycin 5 = ceftriaxone 6 = cefuroxime 

7 = ciprofloxacin 8 = other ________________________________ 9 = unknown 10 = clarithromycin 11 = doxycycline 12 = erythromycin 

13 = none 14 = penicillins 15 = trimethoprim-sulfamethoxazole 16 = tetracycline 

Second Antibiotic Received Date Treatment Initiated __ __ __ __ __ __ __ __

 month day year

Treatment Duration (days) 

LABORATORY INFORMATION

VPD Lab Message Reference Laboratory _______________________________________VPD Lab Message Patient Identifier _________________________________________VPD Lab Message Specimen Identifier _____________________________________

Was Laboratory Testing Done to Confirm Diagnosis? Y=Yes N=No U=Unknown

Was Case Laboratory Confirmed? Y=yes N=no U=unknown Was a Specimen Sent to CDC for Testing? Y=yes N=no U=unknown

Test

Type

Test

Result

Date Specimen

Collected

month day year

Test Result 

Quantitative

Result 

Units

Specimen 

Source

Date Specimen

Sent to CDC

month day year

Specimen

Analyzed Date

month day year

Performing 

Laboratory 

Type

IgA __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgM __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG 

(acute) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG 

(conv) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG 

EIA

(unspec) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG 

toxin __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 

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

DFA __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

PCR __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 

genotype __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

other test 

type __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

unspecified

serology __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

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

Lab Test Interpretation Codes

BP=Bordetella parapertussis

BS=Bordetella species 

P=positive N=negative E=pending 

X=not done 

S=significant rise in titer

NS=no significant rise in titer 

I=Indeterminate Q=equivocal 

O=other (specify) U=unknown

Specimen Source Codes 1=bacterial isolate 10=cataract 19=nasopharyngeal isolate 28=scab 37=nasal sinus

 2=blood 11=CSF 20=nasopharygeal swab 29=serum 38=vesicula swab 

 3=body fluid 12=lesion 21=nasopharygeal washing 30=skin lesion 39=internal nose 

 4=bronchoalveolar lavage 13=microbial isolate 22=nucleic acid 31=specimen 40=throat 

 5=buccal smear 14=crust 23=oral fluid 32=lung 41=tissue 

 6=buccal swab 15=DNA 24=oral swab 33=lavage 42=urine 

 7=capillary blood 16=lesion 25=plasma 34=stool 43=vesicle fluid 

 8=other (specify) 17=macular scraping 26=RNA 35=swab 44=viral isolate 

 9=unknown 18=microbial isolate 27=saliva 36=skin lesion swab 

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

 Page 2 of 5 
 

 VACCINATION HISTORY INFORMATION

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

Was the subject vaccinated per ACIP recommendations? Y=yes N=no U=unknown

Number of doses against this disease received prior to illness onset: 0–6 99=unk (doses)

Date of last dose against this disease prior to illness onset: __ __ __ __ __ __ __ __ (mm/dd/yyyy) 

Vaccine

Type

 

Vaccination Date 

 

month day year

Vaccine

Manuf

Vaccine

Lot Number

Vaccine Expiry 

Date 

month day year

National 

Drug 

Code

Vaccination 

Record 

Identifier

Vaccine Event 

Information 

Source

Vaccine 

Dose 

Number

_______

_______

_______

_______

 _______

 _______

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

_____

_____

_____

_____

_____

_____ 

___________

___________

___________

___________

___________

___________

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

________

________

________

________

________

________

___________

___________

___________

___________

___________

___________

__ __ __ __ __ __ __

 

__ __ __ __ __ __ __

__ __ __ __ __ __ __

__ __ __ __ __ __ __

__ __ __ __ __ __ __

__ __ __ __ __ __ __

_____

_____

_____

_____

_____

_____

VACCINE TYPE CODES

W=DTP whole cell X=Tdap

A=DTaP unspecified K=DTaP-IPV

R=DTaP 5 pertussis V=DTaP-IPV-HepB

H=DTap-Hib N=DTaP-IPV-Hib

D=DT or Td H=DTaP-IPV-HIB-HEPB historical

T=DTP-Hib B=DTaP,IPV,Hib,HepB

P=pertussis only O=other (specify) 

 

VACCINE MANUFACTURER 

CODES

C = Sanofi Pasteur 

L=Wyeth 

S=GlaxoSmithKline

M=Massachusetts Health Department

I=Michigan Health Department

N=North American Vaccine

O = other (specify)

U = unknown

VACCINE EVENT INFORMATION SOURCE CODES

 00= new immunization record 

 01= historical information, source unidentified 

 02= historical information, other provider

 05= historical information, other registry

 06= historical information, birth certificate OTH= other

 07= historical information, school record UNK= unknown 

 08= historical information, public agency

 09= historical information, patient or parent recall

 10= historical information, patient or parent written record

Reason not Vaccinated per ACIP 

1 = religious exemption 5 = MD diagnosis of previous disease 9 = unknown 13 = parent/patient unaware of recommendation 

2 = medical contraindication 6 = too young 10 = parent/patient forgot to vaccinate 14 = missed opportunity

3 = philosophical objection 7 = parent/patient refusal 11 = vaccine record incomplete/unavailable 15 = foreign visitor 

4 = lab evidence of previous disease 8 = other _______________ 12 = parent/patient report of previous disease 16 = immigrant 

EXPOSURE

Epi-linked to confirmed case? Y=yes N=no U=Unknown Outbreak related? Y=yes N=no U=unknown Outbreak Name

__________________

Country of Exposure 

_______________________ State/Province of Exposure _______ County of Exposure ______________________ City of Exposure _____________________

IMPORTATION

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

Imported Country _____________ Imported State _______ Imported County _____________ Imported City ___________________

TRANSMISSION

SETTING

1 = day care 2 = school 3 = doctor’s office 4 = hospital ward 5 = hospital ER 

 6 = hospital outpatient 7 = home 8 = other ____________________ 9 = unknown

10 = college 11 = military 12 = correctional facility 13 = place of worship

14 = international travel 15 = community 16 = work 17 = athletics 

Transmission Mode

________________

 

 Page 3 of 5
EPIDEMIOLOGIC INFORMATION

Mother’s age at infant’s birth (if case <1yr old) Did mother receive Tdap (if case <1yr old)? Y=yes N=no U=unknown

When was Tdap administered? prior to pregnancy during pregnancy postpartum other __________________ unknown

Date Tdap Administered __ __ __ __ __ __ __ __

 month day year

Gestational Age

(if case <1yr old) weeks

Infant Birth Weight

(if case <1 yr old)

Birth Weight Units 

 gram pound 

Was case kilogram ounce -patient a healthcare provider at onset of illness? Y=yes N=no U=unknown

Transmission Setting of Further Spread 

 1 = day care 2 = school 3 = doctor’s office 4 = hospital ward 5 = hospital ER 6 = hospital outpatient clinic 7 = home

 8 = other _______________ 9 = unknown 10 = college 11 = military 12 = correctional facility 13 = church 

14 = international travel 15 = work 16 = athletics 17 = community 18 = no documented spread outside 19 = setting outside household 

One or more suspected sources of infection? Y=yes N=no U=unknown Number of Suspected Sources

Suspected 

Source

Age Age Unit† Sex

Relationship 

to Case Cough Onset Date

month day year 

Number of 

Contacts

Recommended 

Prophylaxis

Relationship Codes 

bro=brother ngh=neighbor 

fth=father oth=other (specify)

fnd=friend sis=sister 

grp=grandparent spo=spouse

mth=mother unk=unknown

Sex Codes 

F=female M=male U=unk

Source 1 __ __ __ __ __ ___ __ __ __ __ __ __ __ __ __ __ __

Source 2 __ __ __ __ __ ___ __ __ __ __ __ __ __ __ __ __ __

Source 3 __ __ __ __ __ ___ __ __ __ __ __ __ __ __ __ __ __

†

Units a=year d=day mo=month wk=week unk=unknown

CASE NOTIFICATION

Condition Code 10190 Immediate National Notifiable Condition Y=yes N=no U=unknown Legacy Case ID _____________ 

State Case ID ________ Local Record ID ________ Jurisdiction Code ____ Binational Reporting Criteria ___ ___ ___ ___ ___ ___ ___

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

 month day year

Date First Electonically Submitted __ __ __ __ __ __ __ __ month day year

Date of Electronic Case Notification to CDC __ __ __ __ __ __ __ __ month day year MMWR Week _____ MMWR Year __________

Current Occupation (type of work case-patient does) 

 _______________________________________ Current Occupation Standardized (NIOCCS code) ___________________

Current Industry (type of business or industry in which casepatient works) ___________________________________________ Current Industry Standardized (NIOCCS code) ____________________

Person Reporting to CDC NAME _________________ (first)

 ________________________________ (last) 

Person Reporting to CDC Email ________________ @ _______________

Person Reporting to CDC Phone Number (__ __ __) __ __ __ __ __ __ __

COMMENTS

 

 

 Page 4 of 5 

 

 

 

 

 
Page 5 of 5 

CLINICAL CASE DEFINITIONŦ

PROBABLE

● In the absence of a more likely diagnosis, illness meeting the clinical criteria

OR 

● Illness with cough of any duration, with 

  At least one of the following signs or symptoms: 

o Paroxysms of coughing; or

o inspiratory whoop; or

o Post-tussive vomiting, or

o Apnea (with or without cyanosis) 

 AND 

  Contact with a laboratory confirmed case (epidemiological linkage)

CONFIRMED

Acute cough illness of any duration, with 

● Isolation of B. pertussis from a clinical specimen OR 

● PCR positive for B. pertussis

Ŧ

https://wwwn.cdc.gov/nndss/conditions/pertussis/case-definition/2020/