Appendix 8-4 

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

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

Country of Birth __________________ Other Birth Place __________________ Country of Usual Residence __________________

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) 

*UNITS a=year d=day mo=month w=week OTH=other UNK=unknown

CASE CLASS STATUS Suspect Probable Confirmed Not a case Unknown Date Confirmed __ __ __ __ __ __ __ __

 month day year 

CASE INVESTIGATION

STATUS CODE 

Approved Deleted Notified Ready for review Reviewed Unknown

Closed In progress Other ___________ Rejected Suspended

CASE DETECTION

METHOD

Laboratory reported Prison entry screening Routine physical exam Self-referral

Prenatal testing Provider reported Other _________________ Unknown

CASE 

CONFIMATION 

METHOD

Active surveillance Epi-linked Local/state specified Occupational disease surveillance

Case/outbreak investigation Lab diagnosis Medical records review Other (specify) __________________

Clinical diagnosis Lab reporting No information given Provider certified 

CLINICAL INFORMATION

Hospitalized? Y=yes N=no U=unknown Hospital Admit Date __ __ __ __ __ __ __ __ month day year

Hospital Discharge Date __ __ __ __ __ __ __ __ month day year 

Hospital Stay Duration 0 – 998 

 999=unknown days 

Illness Onset Date __ __ __ __ __ __ __ __

 month day year

Illness End Date __ __ __ __ __ __ __ __

 month day year

Illness Duration ______ Illness Duration Units* _____ Date of Diagnosis __ __ __ __ __ __ __ __

 month day year

Pregnancy Status

Y=yes N=no U=unknown 

SIGNS and 

SYMPTOMS 

 

 Y N U Onset Date Duration 

Rash __ __ __ __ __ __ __ __

month day year

__ __ __ Was rash generalized?

Y=yes N=no U=unknown 

Age at rash onset? 

Age Type Units 

Fever __ __ __ __ __ __ __ __

month day year

Highest Measured 

Temperature ▪ 

Temperature Units

 °Cel °F

 Y N U Y N U Y N U

Cough Conjunctivitis Other (specify) _____________________ 

Coryza Unknown Y=Yes N=No U=Unknown

 

COMPLICATIONS

 Y N U Y N U Y N U

Croup Otitis Pneumonia Chest X-ray 

for 

Pneumonia

 Positive

 Negative

 Not Done

 Unknown

Diarrhea Thrombocytopenia Unknown

Encephalitis Other (specify) _________ Died?

Hepatitis Date of Death __ __ __ __ __ __ __ __ (mm/dd/yyyy)

Mar 2019 Page 1 of 4
 

LABORATORY TESTING

VPD Lab Message Reference Laboratory _____________________________ VPD Lab Message Patient Identifier

____________________________ VPD Lab Message Specimen Identity ____________________________

Was there laboratory testing done to confirm the 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

Test Result

Quantitative

Result

Units

Specimen

Source (Type)

Specimen

Source (Site)

Date Specimen

Collected

mm/dd/yyyy)

Date Specimen

Sent to CDC

(mm/dd/yyyy)

Specimen

Analyzed Date

(mm/dd/yyyy)

Performing

Laboratory

Type

IgM EIA

capture __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgM EIA __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG EIA

acute __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG EIA

conval __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IF

IgG Ab __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

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

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

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

Ag by IIFA __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

OTHER __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

unspecified

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

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

Test Results Codes

P=positive N=negative 

X=not done I=Indeterminate 

E=pending O=other

NS=no significant rise in titer 

PS=significant rise in titer 

U=unknown

Specimen Source (Type) Codes

1=bacterial isolate 8=cataract 15=NP aspirate 22=RNA 29=lavage 36=throat swab 

2=blood 9=CSF 16=NP swab 23=saliva 30=stool 37=tissue 

3=body fluid 10=crust 17=NP washing 24=scab 31=swab 38=urine 

4=BAL 11=DNA 18=nucleic acid 25=serum 32=swab (skin lesion) 39=vesicle fluid 

5=buccal smear 12=lesion 19=oral fluid 26=skin lesion 33=swab (nasal sinus) 40=viral isolate 

6=buccal swab 13=macular scraping 20=oral swab 27=specimen 34=vesicular swab 41=other 

7=capillary blood 14=microbial isolate 21=plasma 28=lumg 35=swab (internal nose) 42=unknown 

Genotype 

Sequence 

A B2 B3 C1 C2 D2 D3 D4 D5 D6 D7 D8 

D9 D10 G2 G3 H1 H2 other unknown

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

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IMPORTATION AND EXPOSURE INFORMATION

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 ___________________

IMPORT STATUS: Did onset occur within 7-21 days of entering the U.S. following any travel? Y=yes N=no U=unknown

IMPORT STATUS: US-Acquired 1=import-linked case 2=imported virus case 3=endemic case 4=unknown source case 5=other __________ 

Traceable to international import? Y=yes N=no U=unknown Was case a healthcare provider? Y=yes N=no U=unknown

INTERNATIONAL 

DESTINATIONS 

OF RECENT 

TRAVEL 

____________________

____________________ Travel Return Date __ __ __ __ __ __ __ __ 

 month day year

Length of time in the U.S since last

travel: _____________________ 

____________________

____________________ Travel Return Date __ __ __ __ __ __ __ __ 

 month day year Units†

 Length of Time in the U.S. ______ 

Is this case epi-linked to another confirmed or probable case? Y=yes N=no U=unknown 

Outbreak related? Y=yes N=no U=unknown Outbreak Name __________ Investigation Start Date __ __ __ __ __ __ __ __

 month day year 

Country of Exposure _____ State/Province of Exposure County of Exposure ________ City of Exposure________

TRANSMISSION SETTING Transmission Mode ______________________________ 

1 = day care 4 = hospital ward 7 = home 10 = college 13 = place of worship 16 = work

2 = school 5 = hospital ER 8 = other __________________ 11 = military 14 = international travel 17 = athletics 

3 = doctor’s office 6 = hospital outpatient 9 = unknown 12 = correctional facility 15 = community 

Age & setting verified: does the age of the case match or make sense for the listed transmission setting? Y=yes N=no U=unknown

†UNITS a=year h=hour mo=month w=week d=day min=minute s=second OTH=other UNK=unknown

VACCINATION HISTORY

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

Number of vaccine doses received before first birthday? 0 – 6 99 = unknown (doses) Was case-patient vaccinated 

as recommended by the ACIP?

 Y=yes 

 N=no U=unknown 

Number of vaccine doses received on or after first birthday? 0 – 6 99 = unknown (doses)

Number of vaccine doses received prior to illness onset? 0–6 99=unknown (doses) 

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

Vaccine

Type 

Vaccination Date

 

month day year

Vaccine

Manuf

Vaccine

Lot Number

Vaccine Expiration 

Date 

 

month day year

National 

Drug Code

 

Vaccination 

Record 

Identifier 

Vaccine Event 

Information 

Source

Vaccine 

Dose 

Number

_____

_____

_____

_____

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

_____

_____

_____

_____

_____________

_____________

_____________

_____________

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

_________

_________

_________

_________

___________

___________

___________

___________

________

________

________

________

____

____

____

____

VACCINE TYPE CODES

A=MMR R=rubella 

B=mumps virus vaccine RM=rubella/mumps

MR=M/R MM=MMRV

M=measles virus vaccine O=other 

U=unknown N=no vaccine administered 

VACCINE

MANUFACTURER 

CODES

M = Merck

 O = other

 U = unknown

VACCINE EVENT INFORMATION SOURCE CODES

00=new immunization record 08=historical information, public agency

01=historical information, source unspecified 09=historical information, patient/parent recall 

02=historical information, other provider 10=historical information, patient/parent’s 

05=historical information, other registry written record

06=historical information, birth certificate 11=immunization information system (IIS) 

07=historical information, school record UNK=unknown OTH=other 

 Page 3 of 4

 
REASON NOT VACCINATED PER ACIP 

1 = religious exemption 6 = too young 11 = vaccine record incomplete/unavailable 

2 = medical contraindication 7 = parent/patient refusal 12 = parent/patient report of previous disease 

3 = philosophical objection 8 = other ______________________ 13 = parent/patient unaware of recommendation 

4 = lab evidence of previous disease 9 = unknown 14 = missed opportunity 16 = immigrant 

5 = MD diagnosis of previous disease 10 = parent/patient forgot to vaccinate 15 = foreign visitor 

VACCINE HISTORY COMMENTS 

CASE NOTIFICATION

Condition Code 10140 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 Report First Electonically Submitted __ __ __ __ __ __ __ __

 month day year

Date of Electronic Case Notification to CDC __ __ __ __ __ __ __ __ 

 month day year

MMWR Week ______ MMWR Year ________________ 

Notification Result Status Final results Record coming as correction Results cannot be obtained

Person Reporting to CDC __________________________ (first)

NAME _______________________________ (last)

Person Reporting to CDC Email ____________________ @ ____________

Person Reporting to CDC Phone No. (__ __ __) __ __ __ __ __ __ __

Current Occupation _______________________________ Current Occupation Standardized _________________________

Current Industry __________________________________ Current Industry Standardized _____________________________

COMMENTS 

CLINICAL CASE DEFINITION ₸

An acute illness characterized by: 

▪ Generalized, maculopapular rash lasting ≥3 days; and

▪ Temperature ≥101°F or 38.3°C; and

▪ Cough, coryza, or conjunctivitis.

PROBABLE

In the absence of a more likely diagnosis, an illness that meets the clinical description with: 

 ▪ No epidemiologic linkage to a laboratory-confirmed measles case; and 

 ▪ Noncontributory or no measles laboratory testing.

CONFIRMED 

An acute febrile rash illness§ with:

▪ Isolation of measles virus¶ from a clinical specimen; or

▪ Detection of measles-virus specific nucleic acid¶ from a clinical specimen using polymerase chain reaction; or

▪ IgG seroconversion§ or a significant rise in measles immunoglobulin G antibody¶ using any evaluated and validated method; or

▪ A positive serologic test for measles immunoglobulin M antibody¶#; or

▪ Direct epidemiologic linkage to a case confirmed by one of the methods above.

§ Temperature does not need to reach ≥101°F/38.3°C and rash does not need to last ≥3 days.

¶ Not explained by MMR vaccination during the previous 6-45 days.

# Not otherwise ruled out by other confirmatory testing or more specific measles testing in a public health laboratory.

Case Classification Comment: CDC does not request or accept reports of suspect cases so this category is no longer needed for national 

reporting purposes.

₸CSTE Position Statement 11-ID-18 at https://wwwn.cdc.gov/nndss/conditions/measles/case-definition/2013/

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