Appendix 10-2 

Generic MMG Mumps Surveillance Worksheet Mumps_V1.0_MMG_F_R1_20180504 

Name (Last, First) Hospital Record Number

Address (Street and Number) City PID-11.3 County PID-11.9 State

PID-11.4

Zip Code

PID-11.5

Phone

Reporting Physician/Nurse/Hospital/Clinic/Lab 48766-0 Address Phone

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

Mumps Surveillance Worksheet

County PID-11.9 State PID-11.4 ZIP CODE PID-11.5

Birth Date PID-7

__________________________ 

month day year 

Age 77998-3

_________

999=unknown 

Age Type OBX-6

 0=0-120 years

 1=0-11 months

 2= 0-52 weeks

 3=0-28 days

 9=unknown

Ethnicity H=Hispanic

N=not 

Hispanic

U=unknown

PID-22

Race PID-10

 N=Native American/Alaskan Native

 A=Asian/Pacific Islander

 B=African American

 W=White

 O=Other 32624-9 U=Unknown

Sex PID-8

M=male

F=female

U=unknown

Event Date

______ _____ __________ 

month day year 

Event Type

1=Onset date 11368-8

2=Diagnosis date 77975-1

3-Lab test date OBX-19

4=Reported to County 77972-8

5=Reported to State or

 MMRW report date 77973-6

9=Unknown

 

Reported 77995-9

 

_____ _____ ___________ 

 month day year 

Import Status

1=US-acquired 77982-7

2=International Import

 1=Import-linked

 2=Imported virus

 3=Endemic 

 4=Unknown source

 8=Other 

Report 

Status

77990-0 

1=Confirmed

2=Probable

3=Suspect

4=Unknown

CLINICAL DATA

Parotitis (opposite 2nd

molars?) 56831-1

 Y=yes Unilateral 

 N=No INV919 INV301 

 U=Unknown Bilateral

Jaw Pain? 56831-1

 Y=yes 

 N=No INV919

 U=Unknown

COMPLICATIONS

Meningitis?

67187-5 

 Y=yes

 N=No

 U=Unknown

Deafness?

67187-5 

 Y=yes

 N=No

 U=Unknown

Orchitis? 67187-5

 

 Y=yes

 N=No

 U=Unknown

Salivary Gland Swelling (including parotitis) 56831-1

Onset 85931-4 Duration 85929-8

 month day year 1-998 Number of days

Submandibular ? Sublingual? 999=Unknown

 Y=yes Y=yes 

 N=no INV919 N=unknown INV919

 U=unknown U=unknown

Encephalitis?

67187-5 Y=yes 

 N=No INV920

 U=Unknown

Death? 77978-5

 Y=yes

 N=No

 U=Unknown

Other 67187-5

Complications?

 Y=yes 

 N=No

 U=Unknown

If Yes, please 

specify 67187-5

_______________

Hospitalized? Days Hospitalized

77974-4 78033-8

 Y=yes 

 N=No 

 U=Unknown 999=Unknown NOTES 77999-1

LABORATORY 

Was Laboratory Testing Done for Mumps? LAB630

 Y=yes N=No U=Unknown

EPIDEMIOLOGIC

Date First Reported to Health Department 77970-2

 

month day year 

Date Serologic (IgG) Specimens 

Taken

IgG (acute)

 

 month day year 

Test Used INV290 _____________

Units Reported LAB115 ________

Date Serologic (IgG) Specimens 

Taken

IgG (convalescent) 

 

 month day year 

Test Used INV290 _____________

Units Reported LAB115 ________ 

Result

INV291 

Result 

Codes

 INV291 

P= Significant rise in 

IgG

I = Indeterminate

N = No significant 

rise in IgG

E = Pending

X = Not Done

U = Unknown

Date Case Investigation Started 77979-3

 

month day year

Outbreak Related? 77980-1 If Yes, Outbreak Name

 Y=yes N=No U=Unknown 77981-9 _______________

Transmission Setting (Where did this person acquire 

mumps?) 81267-7

 1=Day care

 2=School

 3=Doctor’s office

 4=Hospital ward

 5=Hospital ER

 6=Hospital outpatient clinic

If Other, Specify Transmission Setting 81267-7__________ 

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INV516
LABORATORY 

Single IgG Specimen Only

 

 month day year 

Test Used INV290 __________

Units Reported LAB115 _______

Date Serologic (IgM) Specimens 

Taken

IgM (1) 

 month day 

year 

IgM (2) 

Other Lab Results

PCR 

 month day 

year 

 

Culture 

 month day year 

Result

INV291 

Result 

Codes

INV291 

P = Positive

I = Indeterminate

N = Negative

E = Pending

X = Not Done

U = Unknown

Were Age and Setting Verified (is age appropriate for 

setting)? 85700-3

 Y=yes N=No U=Unknown 

EXPOSURE

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)

Country -77984-3 State (if Out of State)-77985-0

County-77987-6 City-77986-8

Epi-linked to Another Confirmed or Probable Case?

INV217 

 Y=yes N=No U=Unknown 

VACCINE HISTORY

Vaccinated? (Received mumps-containing 

vaccine?) VAC126 

 Y = Yes

 N = No

 U = Unknown

Notes (History of natural mumps disease?) VAC133

 Vaccination Date Vaccine Type Manufacturer Lot Number

 30952-6 30956-7 30957-5 30959-1 

__ __ __ __ __ __ __ __ ___ ___ __ __ __ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __ ___ ___ __ __ __ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __ ___ ___ __ __ __ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __ ___ ___ __ __ __ __ __ __ __ __ __ __

Vaccine 

Type 

Codes

30956-7 

A=MMR

B=Mumps

O=Other

U=Unknown

Vaccine

Manufacturer 

Codes

30957-5 

M=Merck

O=Other

U=Unknown

Number of Doses Received 

After 1st Birthday VAC129

 

 9=unknown 

If Not Vaccinated, What Was the Reason? VAC149

 1 = Religious Exemption 4 = Lab. Evidence of Previous Disease 7 = Parental Refusal

 2 = Medical Contraindication 5 = MD Diagnosis of Previous Disease 8 = Other 

 3 = Philosophical Objection 6 = Under Age for Vaccination 9 = Unknown 

Notes/Other information 77999-1

Clinical Case Definition (2008) 

An illness with acute onset of unilateral or bilateral tender, self-limited swelling of the parotid and or other salivary gland(s), lasting at 

least 2 days, and without other apparent cause. 

Case Classification (2008) 

Suspected: a case with clinically compatible illness or that meets the clinical case definition without laboratory testing or a case with laboratory tests suggestive of 

mumps without clinical information. 

Probable: a case that meets the clinical case definition without laboratory confirmation and is epidemiologically linked to a clinically compatible case. 

Confirmed: a case that: 1) meets the clinical case definition or has clinically compatible illness, and 2) is either laboratory confirmed or is epidemiologically linked to a 

confirmed case. 

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