Appendix 14-1

Suspected Polio Case Worksheet

REPORT CONTACT

Name (Last, First) Initial Report Date 

Month Day Year

hh hh hhhh 

Address City County State Zip Code Phone

Reporting Laboratory State

PATIENT IDENTIFIERS

Name (Last, First)

City County State Occupation

Birth Date 

Month Day Year

hh hh hhhh

Age at Onset

hhh 

999 = Unknown

Age Type

h 0 = 0–120 Years

1 = 0–11 Months

2 = 0–52 Weeks

3 = 0–28 Days

9 = Age Unknown

Ethnicity

h H = Hispanic

N = Not Hispanic

U = Unknown

Race

h N = Native American / Alaskan Native

A = Asian / Pacific Islander

B = African American

W = White

O = Other

U = Unknown

Sex

h M = Male

F = Female

U = Unknown

Date of Onset of First Symptoms

hh hh hhhh 

 Month Day Year

Date of Onset of Paralysis

hh hh hhhh 

Month Day Year

h Y hh hh hhhh 

hh hh hhhh hh hh hhhh hh hh hhhh hh 

hh hh hhhh hh hh hhhh hh hh hhhh hh 

hh hh hhhh hh hh hhhh hh hh hhhh hh

hh hh hhhh hh hh hhhh hh hh hhhh hh 

hh hh hhhh h h hh hh hhhh 

CLINICAL COURSE

Clinical Course

CSF RESULTS

hh hh hhhh 

Date 

 Month Day Year

WBCs RBCs % Lymph % Polys

CS210384-A

Page 1 of 3

h h h 

Protein Glucose

OUTCOME

Date of 60-day Follow Up

 Month Day Year

Sites of Paralysis

1 = Spinal

2 = Bulbar

3 = Spino-bulbar

Specific Sites 60-day Residual

1 = None

2 = Minor (any minor involvement)

3 = Significant (≤2 extremities, 

major involvement)

4 = Severe (≥3 extremities and 

respiratory involvement) 5 = Death

9 = Unknown

Date of Death

Month Day Year

IMMUNIZATION HISTORY

TOPV within 30 Days Prior to Onset of Symptoms?

 = Yes

N = No

Date 

Month Day Year

Lot Number

VACCINE DATE 1 DATE 2 DATE 3

IPV-containing

Total Doses 

Ever Received Month Day Year

Lot Number

Month Day Year

Lot Number

Month Day Year

Lot Number

TOPV

Total Doses 

Ever Received Month Day Year

Lot Number

Month Day Year

Lot Number

Month Day Year

Lot Number

BOPV

Total Doses 

Ever Received Month Day Year

Lot Number

Month Day Year

Lot Number

Month Day Year

Lot Number

MOPV

Total Doses 

Ever Received Month Day Year

Lot Number

Type

1 

or 

3

Month Day Year

Lot Number

Type

1 

or

3

Month Day Year

Lot Number

Type

1 

or 

3
Appendix 14-2

INJECTIONS RECEIVED WITHIN 30 DAYS PRIOR TO ONSET OF ILLNESS

h hh hh hhhh

hh hh hhhh 

hh hh hhhh

 

h

hh hh hhhh hh hh hhhh

h hh hh hhhh

h hh hh hhhh hhh 

pe

h 

hh hh hhhh hhh h 

Date of First Injection

hh hh hhhh 

Month Day Year

Substance of First Injection

h 

Describe Site of First Injection

h 

Date of Second Injection

hh hh hhhh 

 Month Day Year

Substance of Second Injection

h 

Describe Site of Second Injection

h 

Date of Third Injection

hh hh hhhh 

 Month Day Year

Substance of Third Injection

h 

Describe Site of Third Injection

h 

Date of Fourth Injection

hh hh hhhh 

 Month Day Year

Substance of Fourth Injection

h 

Describe Site of Fourth Injection

h 

Substance of Injection

1 = Vaccine

2 = Antibiotic

3 = Other

Site of Injection

1 = Left Deltoid

2 = Right Deltoid

3 = Left Thigh

4 = Right Thigh

5 = Left Gluteal

6 = Right Gluteal

h h hh hh hhhh

h h hh hh hhhh

hh hh hhhh

hh hh hhhh

Page 2 of 3

EXPOSURE HISTORY

Did Case/Household Member Travel 

 to Endemic/Epidemic Area(s)?

Y = Yes

N = No

Location(s) of Exposure Date of Departure

 Month Day Year

Date of Return

Month Day Year

Was Case/Household Member

Exposed to Person(s) from or 

Returning to Endemic Areas?

Location(s) of Exposure Date of Departure

Month Day Year

Date of Return

Month Day Year

Did Case/Household Member have 

Contact with Known Case?

Y = Yes

N = No

Contact Name 

(Last) 

(First)

Location of Exposure Date of Contact

 Month Day Year

Did Case have Contact 

with OPV Recipient?

Y = Yes

N = No

If “Yes”, Date of Contact with 

Household OPV Recipient

Relation

 Month Day Year

Age

999 = Unknown

Age Ty

If “Yes”, Date of Contact with 

Nonhousehold OPV Recipient

Relation

Month Day Year

Age

999 = Unknown

Age Type

Date Contact Received OPV

 Month Day Year

Dose Number Lot Number

Age Type

0 = 0–120 Years

1 = 0–11 Months

2 = 0–52 Weeks

3 = 0–28 Days

9 = Age Unknown

LABORATORY INFORMATION 

 AL

Y

OC

OR

ATE OR L

T

T

LABORA

S

SERUM SPECIMENS SUBMITTED

Laboratory Name

SERUM 1

P1, P2, 

or P3 

1 = P1

2 = P2

3 = P3

Test

1 = Neut.

2 = CF

Result Date Drawn/Obtained

 Month Day Year

SERUM 2

P1, P2, 

or P3 

1 = P1

2 = P2

3 = P3

Test

1 = Neut.

2 = CF

Result Date Drawn/Obtained

 Month Day Year

SPECIMENS SUBMITTED FOR ISOLATION

SPECIMEN 1

Results Laboratory 

Name

Specimen 

Type Date Drawn/Obtained

Month Day Year

SPECIMEN 2

Results Laboratory 

Name

Specimen 

Type Date Drawn/Obtained

Month Day Year
Page 3 of 3

Appendix 14-3

LABORATORY INFORMATION (Continued) 

h hh

hh hh

h h hhh

 hhh

 hhh

 hhh

h

h

h

h

hhhh

h hh

hh hh

h h

VESTIGATIONS 

CDC LABORATORY

SERUM SPECIMENS SENT TO CDC

h h

SERUM 1

1 = P1

2 = P2

3 = P3

hh hh hhhh

h h hh hh hhhh

SPECIAL IN

h hh hh hhhh h hh hh 

h h

P1, P2, 

or P3 Test

1 = Neut.

2 = CF

Result Date Drawn/Obtained

Month Day Year

SERUM 2

P1, P2, 

or P3 

1 = P1

2 = P2

3 = P3

Test

1 = Neut.

2 = CF

Result Date Drawn/Obtained

Month Day Year

SPECIMENS FOR POLIO VIRUS ISOLATION SENT TO CDC

SPECIMEN 1

Specimen 

Type

Results 

(Viral 

Type)

Strains 

(Characterization 

Results)

1 = Oligo- nucleotide 2 = Genomic 

Sequencing

3 = Polymerase 

Chain Reaction

Date Received

Month Day Year

Date Obtained

Month Day Year

SPECIMEN 2

Specimen 

Type

Results 

(Viral 

Type)

Strains 

(Characterization 

Results)

1 = Oligo- nucleotide 2 = Genomic 

Sequencing

3 = Polymerase 

Chain Reaction

Date Received

Month Day Year

Date Obtained

Month Day Year

EMG Conducted?

1 = Yes

2 = No

EMG Results Date of EMG

Month Day Year

Nerve Conduction?

1 = Yes

2 = No

Nerve Results Date Nerve Conduction

Month Day Year

Immune Deficiency Diagnosed Prior to OPV Exposure?

1 = Yes

2 = No

3 = Other

Diagnosis

Immune Studies Performed HIV Status

1 = Positive

2 = Negative

9 = Unknown

ADDITIONAL COMMENTS