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OUTBREAK SETTING. Select a setting for the cluster/outbreak from the drop down menu. If “other” is

selected, please specify the setting in the cell.

Instructions for Completing the Varicella Outbreak Surveillance Reporting Worksheet 

GENERAL. Please complete the Varicella Outbreak Surveillance Reporting Worksheet to keep track of the 

number of cases associated with varicella clusters/outbreaks each year. Each case that is associated with a 

cluster (3-4 cases) or outbreak (5 or more cases) of varicella (epidemiologically linked), regardless of 

household status, should be listed in the line list on the ‘Outbreak Sheet’. Please keep a running list of 

cases for the year. Add outbreak cases for each new quarter of report to the previous list and submit 

the entire list each quarter. Please complete as much information as possible for each case. Listing each 

case and their information will help provide the data needed to assess characteristics of cases associated 

with varicella clusters/outbreaks to help guide control and prevention strategies. 

Reports should be submitted quarterly to CDC via email: alopez@cdc.gov or fax: 404-315-3398. 

Cover Sheet 

1. SITE REPORTING. Select Grantee site from drop down menu.

2. NAME OF PERSON REPORTING. Name of person completing worksheet.

3. PHONE. Phone number of person completing worksheet.

4. EMAIL. Email of person completing worksheet.

5. QUARTER OF REPORT. Select the current reporting quarter. Quarters are based on the calendar year

(January to December).

6. YEAR OF REPORT. Enter the year of report.

7. TOTAL NUMBER OF OUTBREAKS. Enter the cumulative number of outbreaks identified through current

period of report.

Outbreak Sheet 

A. CASE #. This is to keep track of the total number of cases reported during the project year (August to July)

and does NOT need to be changed.

B. GRANTEE. Select Grantee site from drop down menu.

C. OUTBREAK NAME OR ID. Name or ID given to the cluster/outbreak that the case is associated with. The

outbreak name/ID is important because it will allow us to group together cases from the same

cluster/outbreak, and will be used to generate information on cluster/outbreak size and duration.

D.

E. CASE ID. Grantee assigned ID for each case associated with cluster/outbreak. 

F. RASH ONSET DATE. Case-patient’s rash onset date.

G. AGE. Case-patient’s age at time of illness.

H. NUMBER OF LESIONS. Enter range of lesions for case-patient. Valid values include: <50, 50-249, 50-500,

250-499, ≥500, Unknown. Select from drop down menu. **If case-patient has <50 lesions, please enter 

the number of lesions in the cell, if known. ***Please only enter 'unknown' if number of lesions truly 

unknown. 

I. VACCINATED WITH VARICELLA CONTAINING VACCINE. Was case-patient vaccinated with varicellacontaining vaccine? Select from drop down menu. 

( Apri l 2017 )
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J. IF VACCINATED, # OF DOSES. If case-patient vaccinated with varicella-containing vaccine, how many doses

were received? Select from drop down menu.

K. DATE OF VACCINATION (DOSE 1). Date of vaccination for dose 1 (MM/DD/YYYY), if known.

L. DATE OF VACCINATION (DOSE 2). Date of vaccination for dose 2 (MM/DD/YYYY), if known. If ≥3 doses

given, please provide dates of vaccination for additional doses in COMMENTS (column R).

M. HISTORY OF VARICELLA DISEASE. Did the case-patient have varicella in the past, before this current

episode? Select from drop down menu.

N. HOW HISTORY OF DISEASE ASSESSED. If case-patient had history of varicella disease in the past, how was it

assessed? Select from drop down menu.

O. WAS CASE LABORATORY CONFIRMED. Was a specimen collected for laboratory confirmation and the case

was laboratory-confirmed as having varicella? A case would be considered laboratory-confirmed if (1) VZV

was detected by PCR from a skin lesion (ideally vesicles or crusts/scabs), (2) positive VZV IgM, or (3) 4-fold

rise in IgG antibody from acute to convalescent sera. Select from drop down menu.

P. WAS CASE HOSPITALIZED. Was the case-patient hospitalized because of this illness? Select from drop down

menu.

Q. COMPLICATIONS. Specify any complications that the case-patient experienced because of this illness.

R. COMMENTS. List any other comments about this case-patient that are helpful, such as source of exposure,

whether case-patient is in the same household as another case-patient that is part of the cluster/outbreak,

immunocompromised status if known, did varicella illness result in death, other outbreak setting from those

listed in drop down menu for OUTBREAK SETTING (column D), additional dates of vaccination if vaccinated

with ≥3 doses, etc.

( April 2017 )