Appendix 12

CDC • National Center for Immunization and Respiratory Diseases

PERTUSSIS DEATH WORKSHEET

This supplemental worksheet should be used for all known laboratory-diagnosed or epidemiologically-linked pertussis-related deaths, 

whether or not the decedent meets the CSTE pertussis case definition requirements for reporting. This worksheet is not intended for 

use among decedents with clinical suspicion of pertussis in the absence of laboratory testing or epidemiologic linkage to another 

laboratory-confirmed case. At a minimum, pertussis should be listed as a discharge diagnosis, cause of death, or contributing 

condition. Information for this worksheet should be obtained from surveillance case investigations, hospital records, and/or death 

certificates. Where appropriate, this information should match the information reported through NNDSS to CDC.

Decedent State of Residence: 

Decedent Information

Information Type Information

State surveillance ID (if reported)

County of residence

State where death occurred

Date of birth

Country of birth

Gestational age at birth (decedents <1 year of age only)†

Cough onset date*

Date of death

Sex

Race

Ethnicity

† Gestational age should be reported in weeks and should reflect the number of completed weeks of gestation at the time of death.

* If cough not apparent (e.g. infants presenting with apnea, cyanosis, etc.) enter date of symptom onset.

Clinical Symptoms, Complications, Lab Testing and Epidemiologic Linkage, check all that apply:

Clinical symptoms Cough Paroxysms Post-tussive vomiting Whoop Apnea

Cyanosis Fever Rhinorrhea Other: None

Cough duration (days) Unknown

Pertussis laboratory results Culture+ PCR+ Serology+

 Respiratory Panel+: Other: 

Complications experienced Pneumonia Encephalopathy Seizures Lymphocytosis

 Other: None

Was decedent hospitalized? Yes No Unknown

If yes, dates of hospital admission and discharge or death: (MM/DD/YYYY) through (MM/DD/YYYY)

Treatments/Interventions Antibiotics Start date: (MM/DD/YYYY)

Intubation Date: (MM/DD/YYYY)

ECMO Start date: (MM/DD/YYYY)

Other (specify): Date: (MM/DD/YYYY)

None Unknown

Epi-linked to a lab-confirmed case? Yes No Unknown

Family history of cough? Yes No Unknown

CS302457
Underlying Health Issues, check all that apply: None Unknown

Please select any chronic or acute health conditions that the decedent had prior to his/her pertussis infection.

AIDS or CD4 count <200 

Alcohol abuse, current

Alcohol abuse, past 

Aspiration, history of

Asthma

Atherosclerotic Cardiovascular Disease/CAD

Bone marrow transplant (BMT)

Bronchopulmonary dysplasia (BMD), history 

of (also called chronic lung disease (CLD))

Cerebral vascular accident/stroke

Chronic kidney disease

Cirrhosis/liver failure

Complement deficiency

Congenital heart disease

Current chronic dialysis

Cystic fibrosis

Dementia

Diabetes mellitus

Emphysema/COPD

Heart failure/CHF

HIV infection

Hodgkin’s Disease/lymphoma

Immunoglobulin deficiency

Immunosuppressive therapy 

(steroids, chemo, radiation)

IVDU, current*

IVDU, past*

Leukemia

Multiple myeloma

Multiple sclerosis

Nephrotic syndrome

Neuromuscular disorder

Obesity

Other drug use, current*

Other drug use, past*

Parkinson’s Disease

Peripheral neuropathy

Plegias/paralysis

Pulmonary hypertension

Reactive airway disease

Seizure/seizure disorder

Sickle cell anemia

Smoking, current*

Smoking, past*

Solid organ malignancy

Solid organ transplant

Splenectomy/asplenia

Systemic lupus erythematosus (SLE)

Other chronic lung conditions

Other prior illnesses:

*Current = within the previous 12 months. Past = more than 12 months ago. 

Co-Infections and Other Diagnoses, check all that apply: None Unknown

Please select any diagnoses or other infections identified via laboratory testing during the decedent’s pertussis illness.

Respiratory Syncytial Virus (RSV)

Rhinovirus

Coronavirus

Influenza A

Influenza B

Parainfluenza

human Metapneumovirus (hMPV)

Adenovirus

Other: 

Other: 

Other: 

Decedent Pertussis Vaccination History (complete if not already available on surveillance case report form)

Unvaccinated Unknown

Dose Vaccine (DTP, DTaP, Tdap, etc.) Date Administered Manufacturer/Lot #

1

2

3

4

5

6

7

8

Data should be obtained from: provider medical records, immunization registries, shot cards/other family records, patient/parent report (no record), 

or school records.
Maternal Tdap History (For pertussis decedents <12 months of age only)

Unvaccinated Unknown

Dose Date 

Administered

Pregnancy 

Status at 

Administration**

If Pregnant at 

Administration, 

Week of Pregnancy±

Delivery/Expected 

Delivery Date Manufacturer/Lot #

1

2

3

4

5

6

7

8

**Pregnancy status responses include: Pregnant, Post-Partum, and Neither.

± Fill in the number of completed weeks of pregnancy at the time of mother’s Tdap administration.

Post Mortem Examination and Death Certificate Information

Was a post-mortem exam done? Yes No Unknown

Is death certificate available? Yes No Unknown

Causes of death: Unknown

a. ICD-10 code: 

b. ICD-10 code: 

c. ICD-10 code: 

d. ICD-10 code: 

Contributing conditions: Unknown

a. ICD-10 code: 

b. ICD-10 code: 

c. ICD-10 code: 

d. ICD-10 code: