For Local Use Only VARICELLA SURVEILLANCE WORKSHEET

Name State Case I.D. Number LAST / FIRST / MIDDLE

Current Reporting Physician/

Address NUMBER / STREET / APT. NUMBER Nurse/Hospital/

 CITY / COUNTY / STATE ZIP CODE Clinic/Lab ADDRESS

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

Detach here — Transmit only lower portion if sent to CDC

VARICELLA suRVEILLAnCE woRkshEEt

Reported by: State County

Form Approved

OMB No. 0920-0728

Exp. Date 2/28/2011

 1. Date of Birth cc cc cccc 	 	 MONTH DAY YEAR

 2. Current Age ccc

 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 Unknown

 REPoRtInG souRCE

 7. Date of cc cc cccc Report MONTH DAY YEAR

 8. Earliest Date cc cc cccc Reported to MONTH DAY YEAR

County

 9. Earliest Date cc cc cccc Reported to MONTH DAY YEAR

State

Department of Health and Human Services

Centers for Disease Control and Prevention

 

 

CLInICAL Y=Yes n=no u=unknown

CS118977

C DI I on t on

10. Diagnosis cc cc cccc Date MONTH DAY YEAR

11. Illness cc cc cccc Onset Date MONTH DAY YEAR

sIGns/sYMP M to s

12. Rash Onset cc cc cccc Date MONTH DAY YEAR

13. Rash c Generalized c Focal c Unknown

Location

If “Focal,” specify dermatome:

If “Generalized,” first noted: (check all that apply) 

 c Face/Head c Legs c Trunk

c Arms c Inside Mouth

 c Other (specify) 

14. How many lesions were there in total?

c <50 c 50–249 c 250–499 c >500

15. Character of Lesions (with <50) Number of lesions:

Macules (flat) present: c Y c N c U Number:

Papules (raised) present: c Y c N c U Number:

Vesicles (fluid) present: c Y c N c U Number:

16. Character of Lesions (all categories—1 to >500)

Mostly macular/papular c Y c N c U 

Mostly vesicular c Y c N c U 

Hemorrhagic c Y c N c U

Itchy c Y c N c U 

Scabs c Y c N c U 

Crops/waves c Y c N c U

17. Did the rash crust? c Y c N c U

If “yes,” how many days until all the

lesions crusted over? Days

If “no,” how many days did the rash last? Days

18. Did the patient have a fever? c Y c N c U

19. Date of cc cc cccc Fever Onset MONTH DAY YEAR

20. Highest measured temperature: °F / °C CIRCLE ONE

21. Total number of days with fever: Days

22. Is patient immunocompromised due c Y c N c U

to medical condition or treatment?

(If yes, specify)

C MPLICA I o t ons

23. Did the patient visit a healthcare c Y c N c U

provider during this illness?

24. Did the patient develop any c Y c N c U

complications that were diagnosed

by a healthcare provider? If “yes”:

Skin/Soft Tissue Infection c Y c N c U

Cerebellitis/Ataxia c Y c N c U

Encephalitis c Y c N c U

Dehydration c Y c N c U

Hemorrhagic Condition c Y c N c U

Pneumonia c Y c N c U

 How diagnosed: c X-ray c MD c U

Other Complications c Y c N c U

 (Specify)

25. Was the patient treated with c Y c N c U

acyclovir, famvir, or any licensed

antiviral for this illness? If “yes,”

Name of medication:

cc cc cccc 	 	 MONTH DAY YEAR

Stop Date cc cc cccc 	 	 MONTH DAY YEAR

Start Date

Varicella Surveillance 05/09/05

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection 

of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of 

information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-0007)
26. Was the patient hospitalized c Y c N c U

 for this illness? If “yes”:

Admission cc	cc	cccc Date		 MONTH DAY YEAR

Discharge cc	cc	cccc Date		 MONTH DAY YEAR

Total duration of stay in the hospital: Days

Hospital

Information NAME 

27. Did the patient die from varicella c Y c N c U

 or complications (including 

 secondary infection) associated 

 with varicella? If “yes”:

Date of cc	cc	cccc Death		 MONTH DAY YEAR

Autopsy performed? c Y c N c U

Cause of death

NOTE: Fill out varicella death worksheet.

 LABoRAtoRY Y=Yes n=no u=uY=Ynknownes n=no u=unknown

28. Was laboratory testing done c Y c N c U

 for varicella? If “yes”:

29. Direct fluorescent antibody (DFA) c Y c N c U

technique?

 Date of DFA cc	cc	cccc 	 		 MONTH DAY YEAR

DFA Result c Positive c Pending

 c Negative c Not Done

 c Indeterminate c Unknown

30. PCR specimen? c Y c N c U

Date of PCR cc	cc	cccc Specimen		 MONTH DAY YEAR

Source of PCR specimen: (check all that apply)

 c Vesicular Swab c Saliva

 c Scab c Blood

 c Tissue Culture c Urine

 c Buccal Swab c Macular Scraping

 c Other

 PCR Result c Positive c Not Done

 c Negative c Pending

 c Indeterminate c Unknown

 c Other

31. Culture performed? c Y c N c U

Date of cc	cc	cccc Culture		 MONTH DAY YEAR

Specimen

Culture c Positive c Pending

Result c Negative c Not Done

 c Indeterminate c Unknown

32. Was other laboratory testing c Y c N c U

done? If “yes”:

Specify c Tzanck smear

Other Test c Electron microscopy

Date of cc	cc	cccc Other Test		 MONTH DAY YEAR

Other Lab c Positive (results consistent with varicella infection)

Test Result c Negative

 c Indeterminate c Not Done

 c Pending c Unknown

Test Result Value

33. Serology performed? c Y c N c U

If “yes”:

Type of c Capture ELISA c Unknown

IgMTest c Indirect ELISA c Other

Date IgM cc	cc	cccc Specimen		 MONTH DAY YEAR

Taken

IgM Test c Positive c Pending

Result c Negative c Not Done

c Indeterminate c Unknown

Test Result Value

34. IgM performed? c Y c N c U

35. IgG performed? c Y c N c U

If “yes”:

Type of IgG Test:

c Whole Cell ELISA (specify manufacturer):

 

c gp ELISA (specify manufacturer):

c FAMA c Latex Bead Agglutination

c Other

Date of cc	cc	cccc IgG-Acute		 MONTH DAY YEAR

IgG-Acute c Positive c Pending

Result c Negative c Not Done

c Indeterminate c Unknown

Test Result Value

Date of IgG- cc	cc	cccc Convalescent MONTH DAY YEAR

IgG-Conv. c Positive c Pending

Result c Negative c Not Done

c Indeterminate c Unknown

Test Result Value

36. Were the clinical specimens sent c Y c N c U

to CDC for genotyping (molecular typing)?

If “yes”:

Date sent for cc	cc	cccc genotyping MONTH DAY YEAR

37. Was specimen sent for strain c Y c N c U

(wild- or vaccine-type) identification?

Strain Type c Wild Type Strain

 c Vaccine Type Strain

	 	 c Unknown
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

cc cc cccc 	 	

 VACCInE InFoRMAtIon Y=Yes n=no u=unknown

Y=Yes n= o n u= nknown u

38. Did the patient receive c Y c N c U

varicella-containing vaccine?

 If “no,” reason:

 c Born outside the United States

c Lab evidence of previous disease

c MD diagnosis of previous disease

c Medical contraindication

c Never offered vaccine

c Parent/patient forgot to vaccinate

c Parent/patient refusal

c Parent/patient report of previous disease

c Philosophical objection

c Religious exemption

c Under age for vaccination

c Other

c Unknown

39. Number of doses received on or

after first birthday: Doses

40. If patient is >=6 years old and received one dose on or

after 6th birthday but never received second dose, what

 is the reason?

c Born outside the United States

c Lab evidence of previous disease

c MD diagnosis of previous disease

c Medical contraindication

c Never offered vaccine

c Parent/patient forgot to vaccinate

c Parent/patient refusal

c Parent/patient report of previous disease

c Philosophical objection

c Religious exemption

c Other

c Unknown

VACCInAtIon RECoRD 

 Vaccination Date(s) 

__ __ /__ __ /__ __ __ __

__ __ /__ __ /__ __ __ __

__ __ /__ __ /__ __ __ __

__ __ /__ __ /__ __ __ __

__ __ /__ __ /__ __ __ __

Vaccine Type Manufacturer Lot Number

EPIDEMIoLoGIC 

41. Case 

Investigation MONTH DAY YEAR

Start Date

42. Has this patient ever been c Y c N c U

diagnosed with varicella before?

 If “yes”:

Age at ccc Diagnosis

Age Type c Years c Days

 c Months c Hours 

 c Weeks c Unknown

43. Previous case c Physician/Health Care Provider

diagnosed by: c Parent/Friend

 c Other

44. Where was the patient born (country)?

45. Is this case epi-linked to another c Y c N c U

confirmed or probable case?

If “yes,” c Confirmed Varicella Case

epi-linked to: c Probable Varicella Case

 c Herpes Zoster Case

46. Transmission c Athletics c Hospital Outpatient Setting c College 		Clinic

(Setting of c Community c Hospital Ward Exposure) c Correctional Facility c International Travel

 c Daycare c Military

 c Doctor’s Office c Place of Worship

 c Home c School

 c Hospital ER c Work

 c Other c Unknown

47. Is this case a healthcare worker? c Y c N c U

48. Is this case part of an outbreak c Y c N c U

of 5 or more cases?

 If “yes”:

 Outbreak Name:

49. Case Status: c Confirmed

 c Probable

 c Suspect

 c Not a Case

 c Unknown

50. MMWR Week:

51. MMWR Year:

PREGnAnt woMEn

52. If the case is female, is/was c Y c N c U

 she pregnant during this 

 varicella illness? 

 If “yes”:

Number of weeks gestation at

 onset of illness (1-45 weeks): Weeks

Trimester c 1st Trimester

at Onset c 2nd Trimester

of Illness c 3rd Trimester

53. General Comments: