Appendix 9-4

 Meningococcal Disease Surveillance Worksheet 

GENERIC MMG MENING MMG (RIBD_V1.0_MMG_PTR_20190530) 

NAME ADDRESS (Street and No.) Phone Hospital Record No. ________________________ _____________________ _____________________________ __________________ ____________________

 (last) (first)

This information will not be sent to CDC

REPORTING SOURCE TYPE 48766-0 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 PID-11.3 ______________________

SUBJECT ADDRESS STATE PID-11.4 ___________________________

SUBJECT ADDRESS COUNTY PID-11.9 ____________________

SUBJECT ADDRESS ZIP CODE PID-11.5 __ __ __ __ __ 

LOCAL SUBJECT ID PID-3 ____________________________ 

CASE INFORMATION 

Date of Birth __ __ __ __ __ __ __ __ 

 PID-7 month day year

Country of Birth _______

78746-5 

Other Birth Place _____

21842-0 Country of Usual Residence _______77983-5 

Ethnic Group H=Hispanic or Latino N=Not Hispanic/Latino O=Other _______________ U=Unknown Sex M=male F=female 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

Age at Case Investigation ________

 77998-3

Age Unit* _______

OBX-6 for 77998-3 Reporting County 77967-8 ________ Reporting State 77966-0 _____

Date Reported __ __ __ __ __ __ __ __

77995-9 month day year

Date First Reported to PHD __ __ __ __ __ __ __ __

 77970-2 month day year

National Reporting Jurisdiction _______

77968-6 

Earliest Date Reported to County __ __ __ __ __ __ __ __ (mm/dd/yyyy) Earliest Date Reported to State __ __ __ __ __ __ __ __ (mm/dd/yyyy) 

Case Class Status Suspected Probable Confirmed Unknown Not a case

CASE INVESTIGATION

STATUS CODE

 םapproved םclosed םdeleted םin progress םnotified ם other____________ 

 ם ready for review ם rejected ם reviewed םsuspended םunknown

Case Report Form Status Chart unavailable after 3 requests Complete Edited & correct Incomplete Quality assurance review change

ABCs State ID ____ Is this a secondary case? Y=yes N=no U=unknown Case Investigation Start Date __ __ __ __ __ __ __ __ (mm/dd/yyyy) 

CLINICAL INFORMATION

 Illness Onset Date __ __ __ __ __ __ __ __

 11368-8 month day year

Illness End Date __ __ __ __ __ __ __ __

77976-9 month day year

Illness Duration ____ 77977-7 

Duration Units* ____

OBX-6 for 77977-7

 Illness Onset Age INV143 Illness Onset Age Units* OBX-6 for INV143 Diagnosis Date 77975-1 __ __ __ __ __ __ __ __ 

 month day year

Hospitalized? Y=yes N=no U=unknown

77974-4

Hospital Admission Date __ __ __ __ __ __ __ __ 

 8656-1 month day year

Hospital Discharge Date __ __ __ __ __ __ __ __

 8649-6 month day year

Duration of Hospital Stay 0 – 998 999=unknown _____ (days) Epi-linked to a laboratory-confirmed case? INV927 Y=yes N=no U=unknown

Does this patient attend a day care facility? INV615 Y=yes N=no U=unknown Facility Name ______________________________

Does this patient reside in a long-term care facility? INV636 Y=yes N=no U=unknown Facility Name ______________________________

Was the patient taking eculizumab/Soliris at the time of disease onset? 427429004 Y=yes N=no U=unknown

*UNITS a=year d=day h=hour min=minute mo=month s=second wk=week UNK=unknown

SYMPTOMS 

DURING 

COURSE OF 

ILLNESS

 Y N U Y N U Y N U Y N U Y N U

Chills Fever Gastrointestinal illness Pneumonia Vomiting

Cough Headache Muscle pain Rash Unknown

Diarrhea Nausea Photophobia Stiff neck Other _______

[Y=yes N=no U=unknown] INV919

BACTERIAL INFECTION SYNDROME (types of infection caused by organism): INV298 

Abortion with sepsis Cellulitis Epiglottitis Osteomyelitis Pneumonia

Abscess (not skin) Chorioamnionitis Hemolytic Uremic Syndrome Other (specify) Puerperal septicemia

Asymptomatic bacteremia Empyema Infective arthritis Otitis media Septic shock

Bacteremia without focus Endocarditis Meningitis Pericarditis Staphylococcal Toxic Shock

Bacterial septicemia Endometritis Necrotizing fasciitis Peritonitis Unknown

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INV656

INV109

PID-8 PID-22

PID-10 32624-9

77972-8 77973-6

52831-5

78033-8

 56831-1

INV966 INV1093 77979-3

77990-0
Did patient have any underlying causes or prior illnesses? INV235 Y=yes N=no U=unknown If “yes” select below:

UNDERLYING MEDICAL CONDITIONS INV236 Y N U Y N U Y N U

AIDS Current chronic dialysis Neuromuscular disorder 

Alcohol abuse Current smoker None

Asthma Deaf/profound hearing loss Obesity

Blood cancer Dementia Other (specify) __________________

Bone marrow transplant Diabetes mellitus Paralysis

Broken skin Emphysema/COPD Parkinson’s disease

Cancer Former smoker Peptic ulcer

Cancer treatment Hodgkin’s disease Peripheral neuropathy

Cerebrovascular accident HIV infection Peripheral vascular disease

Chronic hepatitis C Immunoglobulin deficiency Premature birth

Chronic respiratory disease Immunosuppressive therapy Renal failure/dialysis

Cirrhosis/liver failure Intravenous drug user Seizure disorder

Cochlear prosthesis Kidney disease Sickle cell trait

Complement deficiency Leukemia Solid organ malignancy

Congestive heart failure Missing spleen Solid organ transplant

Connective tissue disorder Multiple myeloma Splenectomy/asplenia

Coronary arteriosclerosis Multiple sclerosis Systemic lupus erythematosus

Corticosteroids Myocardial infarction Trouble swallowing

CSF leak Nephrotic syndrome Unknown 

Y = yes N = no U = unknown INV662 

Is patient (15-24 years only) currently attending college? Y=yes N=no U=unknown Name of College INV1092 ____________

GRADE 

IN 

SCHOOL 

64990-5

Freshman Senior

Graduate student Sophomore

Junior Unknown

Other (specify) __________________

COLLEGE 

LIVING

SITUATION

INV1091

Dormitory On campus private room

Off campus at home Other ____________________

Off campus private housing Unknown

Off campus house/apartment with roommate(s)

Weight at Diagnosis

3141-9

Weight Units gram kilogram 

OBX-6 for 3141-9 ounce pound 

Height at Diagnosis 

3137-7 

Height Units centimeter 

OBX-6 for 3137-7 inch 

Recurrent disease with same pathogen? Y=yes N=no U=unknown State ID of 1st occurrence for this pathogen INV976 ____

Pregnancy status at time of first positive culture INV661 Not pregnant nor postpartum Currently Pregnant Postpartum Unknown

If pregnant or postpartum, what was the outcome of the fetus? 63893-2 (select below) 

Live birth/neonatal death Survived, clinical infection Still pregnant Unknown

Induced abortion Survived, no apparent illness Abortion/still birth

Subject died? 

Y=yes N=no U=unknown 

Deceased Date__ __ __ __ __ __ __ 

__ mm/dd/yyyy 

If patient <1 month of age: ▪ Gestational age (weeks) ▪ Birth weight 56056-5 Birth Weight Units OBX-6 for 56056-5 

 Gram Kilogram

Was the patient homeless at time of symptom onset? 32911000 yes Ounce Pound no unknown 

RESIDENCE LOCATION AT

TIME OF INITIAL

CULTURE

 םHome םNon-medical ward םCollege dorm םHomeless םIncarcerated 

 םLong-term Care םLong-term acute care םOther _____________________ םUnknown

Has patient had sex with a male in the past 12 months? yes no unknown did not ask refused to answer

In the 3 months prior to onset of symptoms, how many male sex partners has the patient had? INV605 

Has patient had sex with a female in the past 12 months? STD108 yes no unknown did not ask refused to answer

HIV

STATUS

 55277-8

HIV positive

HIV negative

Unknown

TYPE OF 

INSURANCE

76437-3

Incarcerated Managed care (unspecified) MEDICAID Uninsured

Indian Health Service Other (specify) ___________ MEDICARE Unknown

Managed care Military/VA Private health

IMPORTATION AND EXPOSURE INFORMATION

CASE DISEASE 

IMPORTED CODE

Indigenous In state, out of jurisdiction Unknown

International Out of state Yes, imported, but not able to determine source state/country

Imported Country INV153 ______ Imported State INV154 ____ Imported County INV156 _________ Imported City INV155 ____________

Country of Exposure 77984-3 _______________________________ State or Province of Exposure 77985-0 _____________________________

County of Exposure 77987-6 ________________________________ City of Exposure 77986-8 ____________________________________________

Outbreak related? Y=yes N=no U=unknown Outbreak Name 77981-9 _______ Transmission Mode __ __ __ __ __ __ __ __ __

 

 

 

 

STD107

 75617-1

224311000

77978-5

PID-29

18185-9

 INV975

77982-7

77980-1 77989-2

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LABORATORY INFORMATION

VPD Lab Message Reference Laboratory LAB143

__________________________________________

VPD Lab Message Patient Identifier

LAB598 __________________________

VPD Lab Message Specimen Identifier

LAB125 ______________________________

BACTERIAL LAB278

SPECIES ISOLATED

 Neisseria meningitidis Haemophilus influenzae Group B streptococcus Other (specify)

 Listeria monocytogenes Group A streptococcus Streptococcus pneumoniae 

Was there laboratory testing done to confirm the diagnosis? LAB630 Y=Yes N=No U=Unknown

Laboratory Confirmed? INV164 Y=yes N=no U=unknown Was a specimen sent to CDC for testing? 82314-6 Y=yes N=no U=unknown

Test

Type

INV290

Test

Result

INV291

Date 

Specimen

Collected

68963-8 

 mm dd yyyy

Test Result 

Quantitative

LAB628

Result Units LAB115 

Test 

Method 85069-3

Test Manufacturer LAB650

Date 

Specimen

Sent to 

CDC

85930-6 

mm dd yyyy

Specimen

Type

66746-9

Serogroup 

INV705

Serogroup Method LAB652

Lab Accession Number

INV978

Performing

Laboratory 

Name 

68994-3

Performing Lab Type

82771-7

 

 

 

 

 

 

 

 

LABORATORY TESTING CODES

LAB TEST TYPE

1=antigen 

2=susceptibility 

3=culture 

4=genotyping 

5=Gram stain 

 6=immunohistochemistry 

 7=latex agglutination 

8=other (specify) 

9=unknown

10=PCR

11=serotyping

12=species confirmation

13=genome sequencing

SPECIMEN TYPE

1=amniotic fluid 13=liver 25=pleural fluid

2=BAL 14=lung 26=purpuric lesions

3=blood 15=lymph node 27=respiratory secretion 

4=bone 16=middle ear 28=serum

5=brain 17=muscle/fascia/tendon 29=sinus

6=CSF 18=NP swab 30=spleen

7=heart 19=oropharyngeal swab 31=sputum 

8=other (specify) 20=ovary 32=stool

9=unknown 21=pancreas 33=tracheal aspirate

10=internal body site 22=pericardial fluid 34=urine

11=joint 23=peritoneal fluid 35=vascular tissue 

12=kidney 24=placenta 36=vitreous

 37=wound

SEROGROUP METHOD 1=culture 2=PCR 3=slide agglutination 8=other 9=unknown 

SEROGROUP

1=A 3=C 5=X 7=not-groupable 9=unknown

2=B 4=W135 6=Y 8=other (specify) 10=not tested

TEST RESULT INTERPRETATION

P=positive N=negative I=indeterminate E=pending 

S=significant rise in titer NS=no significant rise in titer 

Q=equivocal X=not done O=other U=unknown

V=vaccine type strain W=wild type strain

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 (specify) 9=unknown

LAB TEST METHOD

A=Antigen Card B=BD Directigen BC=BCID Blood culture panel

BCT=Blood culture MA=MALDI Biotyper 

ME=meningitis/encephalitis panel O=Other (specify) 

W=Wellcogen Rapid Antigen U=Unknown

LABORATORY SUSCEPTIBILITY TESTING

Was any susceptibility data available? LAB222 Y=yes N=no U=unknown 

Antimicrobial Susceptibility Test Type 

LABAST6

Test Method

LABAST7

Susceptibility Interpretation

LABAST8

Performing Laboratory Type

LABAST15

SUSCEPTIBILITY TEST METHOD CODES

A=AGAR Agar dilution method C=DISK DISK dilution (Kirby Bauer) I=Automated testing instrument 

B=BROTH Broth dilution method G=whole genome sequencing S=STRIP Gradient strip (E-test) 

SUSCEPTIBILITY RESULT CODES

S=SUSCEPTIBLE I=INTERMEDIATE N=NOT DONE

R=RESISTANT U=UNKNOWN

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 VACCINATION HISTORY INFORMATION

Vaccinated (has the case-patient ever received a vaccine against this disease)? VAC126 Y=yes N=no U=unknown 

Number of vaccine doses against this disease received prior to illness onset: 82745-1 0 – 6 99=unk (doses) 

Date of last vaccine dose against this disease prior to illness onset? VAC142 __ __ __ __ __ __ __ __ (mm/dd/yyyy)

 

Was case-patient vaccinated as recommended by the ACIP? VAC148 Y=yes N=no U=unknown 

Vaccine

Type

30956-7 

Vaccination 

Date 

30952-6 month day year

Vaccine

Manuf

30957-5 

Vaccine

Lot 

Number

30959-1 

National 

Drug 

Code

VAC153

Vaccine 

Expiration 

Date VAC109

month day year 

Vaccine 

Name 

VAC155

Vaccine 

Event 

Information 

Source

VAC147

Vaccination 

Record 

Identifier

VAC102

Age† 

VAC105

Age 

UnitsŦ

OBX-6 

for 

VAC105

Vaccine 

Dose 

Number

30973-2 

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 _____ 

_ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _

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 _____ 

__________

__________

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__________

__________

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VACCINE TYPE CODES 32=MPSV4 (Menomune) 162=men. B, recombinant 

103=men. C conjugate (Trumenba) 

108=men. ACWY,unspecified 163=men. B, OMV(Bexsero) 

114=MCV4P (Menactra) PHC1560=type not specified 

136=MCV4O (Menveo) OTH=other (specify)

147=MCV4, unspecified 999=unknown 

148=men. C/Y-HIB PRP (MenHibRix 

VACCINE MANUFACTURER 

CODES

 BHA=Baxter Healthcare PFR=Pfizer 

MSD=Merck & Co., Inc. PMC=Sanofi Pasteur

NOV=Novartis SKB=GlaxoSmithKline

OTH=other (specify) WAL=Wyeth 

 UNK=unknown

VACCINE EVENT INFORMATION SOURCE 

CODES

1=Birth certificate 8=Other

2=IIS 9=Unknown

3=Medical record 10=Patient or parent’s written record

4=New immunization record 11=Primary care provider 

5=Other provider 12=Public agency

6=Other registry 13=School record 

7=Patient or parent’s recall 14=Source unspecified 

†Age at 

vaccination

₸Age 

Units

a=year

d=day

mo=month 

wk=week 

OTH=other 

UNK=unk

Reason Not Vaccinated Per ACIP VAC149

1=religious exemption 5=MD diagnosis of previous disease 9=unknown 13=parent/patient unaware of recommendation 

2=medical contraindication 6=too young 10=parent/patient forgot to vaccinate 14=missed opportunity

3=philosophical objection 7=parent/patient refusal 11=vaccine record incomplete/unavailable 15=foreign visitor _____

4=lab evidence of previous disease 8=other ___________________ 12=parent/patient report of previous disease 16=immigrant 

Vaccine History Comments VAC133

CASE NOTIFICATION

CONDITION

CODE OBR-31

10150 Immediate National Notifiable Condition Y=yes N=no U=unknown

77965-2

Legacy Case ID _____ 77997-5

State Case ID ________

77993-4

Local Record ID _______

OBR-3

Jurisdiction Code ____

77969-4

Binational Reporting Criteria ___ ___ ___ ___ ___ ___ ___

77988-4

Date First Verbal Notification to CDC __ __ __ __ __ __ __ __

77994-2 month day year

Date Notification First Electonically Submitted __ __ __ __ __ __ __ __

OBR-7 month day year

Date of Electronic Case (this version) Notification to CDC __ __ __ __ __ __ __ __

OBR-22 month day year

MMWR Week ____ 

77991-8

MMWR Year ______

77992-6

Notification Result Status OBR-25 F = Final C = Record is a correction X = Results cannot be obtained

Person Reporting to CDC Name ____________________ (first)

74549-7 ________________________________ (last)

Person Reporting to CDC Email 74547-1 ________________ @ ____________

Person Reporting to CDC Phone Number 74548-9 (__ __ __) __ __ __ __ __ __ __

Current Occupation 85658-3 _______________________________ Current Occupation Standardized 85659-1 _________________________

Current Industry 85078-4 __________________________________ Current Industry Standardized 85657-5 ____________________________

Comments 77999-1 

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CLINICAL CASE DEFINITION§

SUSPECTED

● Clinical purpura fulminans in the absence of a positive blood culture; or

● Gram-negative diplococci, not yet identified, isolated from a normally sterile body site (e.g., blood or CSF)

PROBABLE

● Detection of N. meningitidis antigen

O

O

o 

o 

In formalin-fixed tissue by immunohistochemistry (IHC); or

In CSF by latex agglutination

CONFIRMED

• Detection of N. meningitidis-specific nucleic acid in a specimen obtained from a normally sterile body site (e.g., blood or 

CSF), using a validated polymerase chain reaction (PCR) assay; or 

● Isolation of N. meningitidis

From a normally sterile body site (e.g., blood or CSF, or less commonly, synovial, pleural, or pericardial fluid); or

From purpuric lesions.

 §//wwwn.cdc.gov/nndss/conditions/meningococcal-disease/case-definition/2015/

 

 

 

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