Appendix 20-5

Varicella Surveillance Worksheet

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 52831-5 ______________ 

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 Sex PID-8 M=male F=female U=unknown Ethnic Group H=Hispanic or Latino N=not Hispanic/Latino

 PID-22 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________ םUnknown

Birth Country 78746-5 _________________ Other Birth Place 21842-0 _______________ Country of Usual Residence 77983-5 _______

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 77972-8 __ __ __ __ __ __ __ __

 month day year

Earliest Date Reported to State 77973-6 __ __ __ __ __ __ __ __

month day year

Case Class Status ם Suspected ם Probable ם Confirmed ם Unknown ם Not a case Case Investigation Start Date __ __ __ __ __ __ __ __

 77979-3 month day year

Case Investigation Status Code INV109 םapproved םclosed םdeleted םin progress םnotified ם other_____ ם rejected ם reviewed םsuspended םunknown

CLINCAL INFORMATION

Hospital Admission Date __ __ __ __ __ __ __ __

 8656-1 month day year

Hospital Discharge Date __ __ __ __ __ __ __ __

 8649-6 month day year

Hospital Stay Duration 0 – 998 _____ 

 78033-8 999=unknown (days)

 Illness Onset Date __ __ __ __ __ __ __ __

 11368-8 month day year

Illness End Date __ __ __ __ __ __ __ __

77976-9 month day year

Illness Duration __

77977-7 

Illness Duration Units* _ OBX-6 for 77977-7 

Date of Diagnosis __ __ __ __ __ __ __ __

 month day year

Pregnancy Status Y=yes N=no U=unknown

 77996-7

REASON FOR 86947-9 

HOSPITALIZATION

Varicella related complications Administration of IV treatment Isolation Non-varicella hospitalization 

 Observation Other ___________________________ Severe varicella presentation Unknown 

RashOnset Date __ __ __ __ __ __ __ __

 81268-5 month day year

Rash Duration 81269-3 _____

(days) 

Was the rash generalized? Y=yes N=no U=unknown

 725119006

Body Regions of Rash

(if rash NOT generalized)

364402001

Arm, hand, torso, back 

Head/face with eye involvement

Head/face without eye involvement

Leg

Neck/shoulder

Pelvis/groin/buttocks/hip

Upper mid-abdomen/flank

Other (specify) _____________________

Unknown

Total Number of Lesions300579006 <50 50-249 50-500 250-499 >500 Unknown If <50 lesions, how many?

Character of Lesions Maculopapular Vesicular other ___________ unknown Were the lesions hemorrhagic? Y=yes N=no U=unknown

Were the lesions itchy? Y=yes N=no U=unknown Did the lesions appear in crops/waves? INV912 Y=yes N=no U=unknown

Did the lesions crust/scab over? INV913 Y=yes N=no U=unknown Is patient immunocompromised? Y=yes N=no U=unknown

If patient immunocompromised, then immunocompromised-associated condition or treatment INV933 _________________ 

Did patient visit a healthcare provider during this illness? VAR128 Y=yes N=no U=unknown Fever? Y=yes N=no U=unknown

Fever Onset Date __ __ __ __ __ __ __ __

 81266-9 month day year

Fever Duration ___ ___ ___

 81264-4 (days)

Highest Temperature ______ . ___

 81265-1 

Temperature Units

OBX-6 for 81265-1 °Cel °F 

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

 OCT/2018 Page 1 of 5 

Generic MMG Varicella MMG

PID-10 32624-9

 

 

 

77990-0

370388006

386661006

418290006

INV911 364637009

246206008

77975-1

Hospitalized? Y=yes77 N974=-n4o U=unknown
COMPLICATIONS

TYPE OF

COMPLICATIONS

67187-5

INV920 Y N U 

cerebellitis/ataxia

dehydration

hemorrhagic condition

 INV920 Y N U 

skin/soft tissue infection

other _________________

varicella encephalitis

 INV920 Y N U D

Pneumonia

Chest X-ray for pneumonia INV923

 Y=yes N=no U=unknown D=not done 

Subject death from this illness or complications of this illness? Y=yes N=no U=unknown Deceased Date __ __ __ __ __ __ __ __

 month day year

TREATMENT

Antiviral medication? VAR139 Y=yes N=no U=unknown Treatment Start Date __ __ __ __ __ __ __ __

 86948-7 month day year

Treatment Duration ______ (days) 

Medication received: 29303-5 acyclovir famciclovir valacyclovirOL other __________________ unknown 

LABORATORY TESTING

VPD Lab Message Reference Laboratory

LAB143 _________________________________

VPD Lab Message Patient Identifier

LAB598 _____________________________

VPD Lab Message Specimen Identifier

LAB125 ____________________________

Was laboratory testing done to confirm the diagnosis? LAB630 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

INV290

Test

Result

INV291

Date Specimen 

Collected

68963-8 

[mm dd yyyy]

Test Result 

Quantitative

LAB628

Result 

Units

LAB115

Specimen 

Source

31208-2 

Date Specimen 

Sent to CDC

85930-6 

[mm dd yyyy]

Date Specimen 

Analyzed

OBX-19

[mm dd yyyy]

Performing 

Laboratory 

Type 82771-7 

IgM

8048-1 

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG

avidity

LAB632

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG

(acute)

LAB637

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG

(conv)

LAB638

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG

EIA

15410-4

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

unspecified

seology

LAB707

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Culture

10860-5 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

DFA

5882-6 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

PCR

11463-5 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Genotype

LAB631 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Other

LAB608 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Strain ID

82746-9 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Unknown

LAB609 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Test Results Codes

P=positive N=negative X=not done 

I=Indeterminate E=pending O=other (specify) 

IN=inadequate NS=no significant rise in IgG 

PS=significant rise in IgG U=unknown 

V=vaccine type strain W=wild type strain

Specimen Source Codes

1=blood 8=other (specify) 15=swab (skin lesion) 

2=bronchoalveolar 9=unknown 16=throat swab 

 3=CSF 10=NP washing 17=tissue 

 4=crust 11=saliva 18=urine 

5=lesion 12=scab 19=vesicle fluid

6=macular scraping 13=serum 20=vesicular swab

7=NP swab 14=skin lesion

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 

 Page 2 of 5 

67453-1

INV164 82314-6

77978-5

PID-29
 

VACCINATION HISTORY

VACCINATED (has the case-patient ever received varicella-containing vaccine)? VAC126 Y=yes N=no U=unknown

Number of vaccine doses received on or after first birthday? VAC129 0 – 6 99 = unknown 

Was case-patient vaccinated as 

recommended by the ACIP?

VAC148 Y=yes N=no U=unknown 

Number of vaccine doses received prior to illness onset? 82745-1 0–6 99=unknown (doses) 

Date of last dose prior to illness onset? vAC142 __ __ __ __ __ __ __ __ [mm/dd/yyyy] 

Vaccine

Type

30956-7 

Vaccination Date 

30952-6 

[mm dd yyyy]

Vaccine

Manuf

30957-5

Vaccine

Lot Number

30959-1

Vaccine Expiry 

Date VAC109 

[mm dd yyyy]

National 

Drug 

Code

VAC153 

Vaccination 

Record 

Identifier

VAC102 

Vaccine Event 

Information 

Source

VAC147

Vaccine 

Dose 

Number

30973-2 

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VACCINE TYPE CODES

 

M=measles/mumps/rubella/varicella [MMRV] 

V = varicella vaccine 

O = other (specify) ________________ 

U= unknown

VACCINE

MANUFACTURER CODES

M = Merck

O = other (specify) ______________

U = unknown

VACCINE EVENT INFORMATION SOURCE CODES

 00= new immunization record 

 01= historical information, source unidentified 

 02= historical information, other provider

 05= historical information, other registry OTH= other _________

 06= historical information, birth certificate UNK= unknown

 07= historical information, school record

 08= historical information, public agency

 09= historical information, patient or parent recall

 10= historical information, patient or parent written record 

REASON NOT VACCINATED PER ACIP VAC149 11 = vaccine record incomplete/unavailable 

 1 = religious exemption 6 = too young 12 = parent/patient report of previous disease

 2 = medical contraindication 7 = parent/patient refusal 13 = parent/patient unaware of recommendation

 3 = philosophical objection 8 = other ________________________ 14 = missed opportunity 

 4 = lab evidence of previous disease 9 = unknown 15 = foreign visitor 

 5 = MD diagnosis of previous disease 10 = parent/patient forgot to vaccinate 16 = immigrant

EPIDEMIOLOGIC

Has patient been diagnosed with varicella before? Y=yes N=no U=unknown Age at previous diagnosis?___ Age Units† OBX-6___

Previous case was diagnosed by VAR152 Parent Physician/Healthcare provider Other_________________ Unknown

If case pregnant at illness onset, weeks gestation? If case pregnant at illness onset, trimester of gestation? 

Is case-patient a healthcare worker? Y=yes N=no U=unknown Epi-linked to a confirmed or probable case? Y=yes N=no U=unknown 

If epi-linked, type of case: VAR155 confirmed varicella probable varicella herpes zoster unknown

Transmission

Setting 81267-7 

1=day care 2=school 3=doctor’s office 4=hospital ward 5=hospital ER 6=hospital outpatient clinic 

7=home 8=other ________________ 9=unknown 10=college 11=military 12=correctional facility 

13=place of worship 14=international travel 15=community 16=work 17=athletics 

Transmission Mode

77989-2 ______________

†

UNITS OBX-6 for INV934 a=year mo=month w=week d=day UNK=unknown

EXPOSURE

Outbreak related? Y=yes N=no U=unknown Outbreak Name 77981-9 ____________ COUNTRY of Exposure 77984-3 ____________

STATE/PROVINCE of Exposure 77985-0 _____ COUNTY of Exposure 77987-6 __________ CITY of Exposure 77986-8 __________

 

VAR150 INV934

223366009 VAR154

81270-1 81271-9

77980-1

Page 3 of 5
 

CASE NOTIFICATION

Condition Code 10030 Immediate National Notifiable Condition Y=yes N=no U=unknown Legacy Case ID 77997-5 ________ 

State Case ID 77993-4 ___ Local Record ID OBR-3 ____ Jurisdiction Code ______ Binational Reporting Criteria __ __ __ __ __ __ __

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

 77994-2 month day year 

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

 OBR-7 month day year 

Date of Electronic Case 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 __________________________ (first)

NAME 74549-7 ________________________________ (last)

Person Reporting to CDC Email __74547-1_______ @ ________________

Person Reporting to CDC Phone Number (__ __ __) __ __ __ __ __ __ __ 

Current Occupation 85658-3 ______________________________ Current Occupation Standardized 85659-1 ___________________________

Current Industry 85078-4 ___________________________________ Current Industry Standardized 85657-5 ______________________________

Comments 77999-1

CLINICAL CASE DEFINITION Ŧ

 

PROBABLE

An acute illness with 

• Diffuse (generalized) maculo-papulovesicular rash, AND

• Lack of laboratory confirmation, AND

• Lack of epidemiologic linkage to another probable or confirmed case

CONFIRMED

An acute illness with diffuse (generalized) maculo-papulovesicular rash, AND 

● Epidemiologic linkage to another probable or confirmed case, OR

● Laboratory confirmation by any of the following: 

o Isolation of varicella virus from a clinical specimen, OR

o Varicella antigen detected by direct fluorescent antibody test, OR

o Varicella-specific nucleic acid detected by polymerase chain reaction (PCR), OR

o Significant rise in serum anti-varicella immunoglobulin G (IgG) antibody level by any standard serologic assay. 

Ŧ

CSTE Position Statement 09-ID-68 at https://wwwn.cdc.gov/nndss/conditions/varicella/case-definition/2010 

 Page 4 of 5 

OBR 77965-2 -31

74548-9

77988-4 77969-4