Rubella Surveillance Worksheet APPENDIX 16 

NAME (Last, First) Hospital Record No. 

Address (Street and No.) City County Zip Phone 

Reporting Physician/Nurse/Hospital/Clinic/Lab Address Phone 

DETACH HERE and transmit only lower portion if sent to CDC 

Rubella Surveillance Worksheet 

County State Zip 

Birth Date Age 

Unk = 999 

Age Type Ethni 0 = 0-120 years 3 = 0- 28 days H = Hispanic N = Native Amer./Alaskan Native W = White M = Male 

N = Not Hispanic A = Asian/Pacific Islander O = Other F = Female 

U = Unknown B = African American U = Unknown U = Unknown 

1 = 0-11 months 9 = Age unknown 

2 = 0-52 weeks 

city Race Sex 

Month Day Year 

Event Date 

Month Day Year 

Event Type 

1 = Onset Date 4 = Reported to County 

2 = Diagnosis Date 5 = Reported to State or 

3 = Lab Test Date MMWR Report Date

9 = Unknown 

A

Onset Rash Duration 

Outbreak 

ssociated 

Reported 

Month Day Year 

Imported 

1 = Indigenous 

2 = International 

3 = Out of State 

9 = Unknown 

Report Status 

1 = Confirmed 

2 = Probable 

3 = Suspect 

9 = Unknown 

AT DA L CA IN LI

C

Any Rash? Rash

Month Day Year 

Y = Yes 

N = N o 

U = Unknown 

Fever? If Recorded, Highest Measured Temp. 

Y = Yes 36.0 - 110.0 N = N o . Degrees 

U = Unknown 999.9 = Unknown 

----------------------------------------------------- ----------------------------------------------- COMPLICATI

0 - 30 Days 

99 = Unknown 

Unk = 999 ONS 

Encephalitis? 

Y = Yes 

N = N o 

U = Unknown 

Arthralgia/Arthritis? 

Y = Yes 

N = N o 

U = Unknown 

Thrombocytopenia? 

Y = Yes 

N = N o 

U = Unknown 

Death? 

Y = Yes 

N = N o 

U = Unknown 

Other Complications? 

Y = Yes 

N = N o 

U = Unknown 

If Yes, Please Specify: 

Hospitalized? Days Hospitalized 

Y = Yes 0 - 998 N = N o 999 - Unknown U = Unknown 

Arthralgia/ 

Arthritis? 

Y = Yes 

N = N o 

U = Unknown 

Lymphadenopathy? 

Y = Yes 

N = N o 

U = Unknown 

Conjunctivitis? 

Y = Yes 

N = N o 

U = Unknown 

Y LABORATOR

Was Laboratory Testing For Rubella Done? 

Y = Yes 

N = N o 

U = Unknown 

Date IgM Result 

Specimen Taken P = Positive E = Pending 

N = Negative X = Not Done

I = Indeterminate 

U = Unknown Month Day Year 

Date IgG Acute 

Specimen Taken 

Month Day Year 

Result 

P = Significant Rise in IgG 

N = No Significant Rise in IgG

I = Indeterminate 

E = Pending 

X = Not Done 

U = Unknown 

Date IgG Convalescent 

Specimen Taken 

Month Day Year 

Other Lab Result 

P = Positive 

N = Negative 

I = Indeterminate 

X = Not Done 

E = Pending 

U = Unknown 

Specify Other Lab Method: 

Vaccinated? Y = Yes 

N = N o 

U = Unknown 

(Received rubella-containing vaccine?) 

If Not Vaccinate

1 = Religious Exemption 

2 = Medical Contraindication 

3 = Philosophical Objection 

4 = Lab. Evidence of Previous Disease 

5 = MD Diagnosis of Previous Disease 

Vaccination Date 

Month Day Year 

Vaccine Vaccine Manuf. Lot Number 

Type 

Vaccine Type 

Codes 

A = MMR 

B = Rubella 

O = Other 

U = Unknown 

Vaccine Manufacturer Codes 

M = Merck 

O = Other 

U = Unknown 

Number of doses received ON or AFTER 1st birthday 

d, What Was The Reason? 

6 = Under Age For Vaccination 

7 = Parental Refusal 

8 = Other 

9 = Unknown 

EPIDEMIOLOGIC 

Date First Reported to a Health Department 

Month Day Year 

Date Case Investigation Started 

Month Day Year 

Transmission Setting (Where did patient acquire rubella?) 

1 = Day Care 6 = Hospital Outpatient Clinic 11 = Military 

2 = School 7 = Home 12 = Correctional Facility 

3 = Doctor's Office 8 = Work 13 = Church 

4 = Hospital Ward 9 = Unknown 14 = International Travel 

5 = Hospital ER 10 = College 15 = Other 

If Other, Specify Transmission Setting:________________________________ 

Were Age and Setting Verified? (Is age appropriate for Y = Yes 

N = N o setting) U = Unknown 

Source of Exposure For Current Case (Enter State ID if source 

was an in-state case; enter Country if source was out of U.S.; enter State if source 

was out-of-state) 

Epi-Linked to Another Confirmed or Probable Case? 

Y = Yes 

N = N o 

U = Unknown 

Outbreak Related? If Yes, Outbreak Name 

Y = Yes 

N = N o 

U = Unknown 

Indicates epidemiologically important 

items not yet on NETSS screen 

Country of Birth 

Y R TO SIH NE I VACC

CS106190

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WOMEN PREGNANT ----------------------------------------------------- DETACH HERE and transmit only lower portion if sent to CDC -----------------------------------------------

Was Patient Pregnant? Number of Weeks Gestation (or Trimester) 1st = First Trimester 1 = 1 Week

Y = Yes at Onset of Illness 2nd = Second Trimester Or 2 = 2 Weeks

N = No 3rd = Trimester 3 = 3 Weeks

U = Unknown Etc. – continue up to 45 weeks

Prior Evidence of Serological Immunity? Year of Test Age of Patient at Time of Test

Y = Yes OR N = No

U = Unknown 0 -50

99 - Unknown

Was Previous Rubella Serologically Confirmed? Year of Disease Age of Patient at Time of Disease

Y = Yes OR N = No

U = Unknown 0 -50

99 - Unknown

The information below is epidemiologically important but not included on NETSS screens

Exposure Period Period of Communicability

21 Days 14 Days 7 Days Rash Onset 7 Days

Month Day Year Month Day Year Month Day Year Month Day Year Month Day Year

Contacts of patient during infectious period (7 days before to 7days after rash onset) who are in 1st 5 months of pregnancy

Documented Prior

Name Address/Phone Rubella Immunization?

Y = Yes

N = No

U = Unknown

Y = Yes

N = No

U = Unknown

Y = Yes

N = No

U = Unknown

Month Day Year

Month Day Year

Month Day Year

If Yes, Date

Documented Rubella If No or Unknown,

Seropositivity Before Or Action Taken –

Within 7 Days After First Rubella Serology,

Exposed etc.

Y = Yes

N = No

U = Unknown

Y = Yes

N = No

U = Unknown

Y = Yes

N = No

U = Unknown

Group contacts of patient during infectious period (7 days before to 7 days after rash onset), i.e., households, child care center, school, 

college, workplace, jail/prison, physician’s office/clinic/hospital/emergency room, etc.

Name of Group/Site Address/Phone Notes

Clinical Case Definition:

An illness that has all of the following characteristics: acute onset of generalized maculopapular rash, temperature > 99° F (> 37° C), if

measured, and arthralgia/arthritis, lymphadenopathy, or conjunctivitis.

Case Classification:

Suspected: any generalized rash illness of acute onset

Probable: a case that meets the clinical case definition, has no or noncontributory serologic or virologic testing, and is not epidemiologically

linked to a laboratory-confirmed case

Confirmed: a case that is laboratory confirmed or that meets the clinical case definition and is epidemiologically linked to a laboratoryconfirmed case

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