Pertussis Surveillance Worksheet Appendix 11

NAME (Last, First) Hospital Record No.

Address (Street and No.) City County Zip Phone

Reporting Physician/Nurse/Hospital/Clinic/LabPhone Address Phone

DETACH HERE and transmit only lower portion if sent to CDC

CDC NETSS id County State Zip 

Birth Date

 Month Day Year

Age 

Unk= 999 

Age Type 0 = 0-120 years

1 = 0-11 months

2 = 0-52 weeks

3 = 0-28 days

9 = Age Unknown

Race 

N = Native Amer./Alaskan Native W = White

A = Asian/Pacific Islander O = Other

B = African American U = Unknown

Ethnicity

H = Hispanic

N = Not Hispanic

U = Unknown 

SexM = Male

F = Female

U = Unknown 

Event Date

 Month Day Year

Event Type 

1 = Onset Date

2 = Diagnosis Date

3 = Lab Test Done

4 = Reported to County

5 = Reported to State or 

MMWR Report Date 9 = Unknown

Outbreak

Associated

999 = Unknown

Reported 

Month Day Year

Report Status

1 = Confirmed

2 = Probable

3 = Suspect

9 = Unknown 

CLINICAL DATA

Any Cough? Cough Onset Y = Yes

N = No

U = Unknown Month Day Year

Paroxysmal Cough? Y = Yes

N = No

U = Unknown

Whoop?

Y = Yes

N = No

U = Unknown 

Posttussive Vomiting? Y = Yes

N = No

U = Unknown 

Apnea? Y = Yes

N = No

U = Unknown 

Final Interview Date

 Month Day Year

Cough at Final Interview? Y = Yes

N = No

U = Unknown 

Duration of Cough at Final Interview 

Days

0–150

999 = Unknown

COMPLICATIONS

Chest X-ray for Pneumonia P = Positive

N = Negative X = Not Done

U = Unknown

Seizures Due to Pertussis Y = Yes

N = No

U = Unknown 

Acute Encephalopathy Due to Pertussis Y = Yes

N = No

U = Unknown 

Hospitalized? Y = Yes

N = No

U = Unknown

Days Hospitalized? 0-998

999 = Unknown 

Died? Y = Yes

N = No

U = Unknown 

TREATMENT

Were Antibiotics Given? Y = Yes

N = No

U = Unknown 

1 = Erythromycin (incl. pediazole, ilosone)

2 = Cotrimoxazole (bactrim/septra)

3 = Clarithromycin/azithromycin

4 = Tetracycline/Doxycycline

5 = Amoxicillin/Penicillin/Ampicillin/Augmentin/Cector/Cefixime

6 = Other

9 = Unknown

Date Started First Antibiotic

 Month Day Year

Days First Antibiotic Actually Taken 0-998

999 = Unknown 

Second Antibiotic Received

See Choices for First Antibiotic Given

Date Started Second Antibiotic 

Month Day Year

Days Second Antibiotic Actually Taken 0-998

999 = Unknown 

LABORATORY

Was Laboratory Testing for Pertussis Done?

Y = Yes

N = No

U = Unknown 

Result Date Specimen Taken

 Month Day Year

Culture

DFA

Serology 1

Serology 2

PCR

RESULT CODES

P = Positive E = Pending X = Not Done U = Unknown

N = Negative I = Indeterminate S = Parapertussis 

VACCINE HISTORY

Vaccinated? (Received any doses of diphtheria,

tetanus, and/or pertussis-containing vaccines)

Y = Yes

N = No

U = Unknown 

Vaccination Date

 Month Day Year

Vaccine

Type*

Vaccine

Manuf* Lot Number

 Vaccine Type 

 W = DTP Whole Cell

Vaccine Manufacturer Codes

C = Sanofi Pasteur

L = Wyeth

S = GlaxoSmithKline

M = Massachusetts Health Department

I = Michigan Health Department

N = North American Vaccine

O = Other

U = Unknown *Record for 

each dose 

Date of Last Pertussis-Containing

Vaccine Prior to Illness Onset

 Month Day Year

Number of Doses of Pertussis-Containing 

Vaccine Prior to Illness Onset

0-6

9 = Unknown 

Reason Not Vaccinated With >_ 3 Doses of Pertussis Vaccine

1 = Religious Exemption

2 = Medical Contraindication

3 = Philosophical Exemption

4 = Previous Pertussis Confirmed by Culture or MD

5 = Parental Refusal

6 = Age Less Than 7 Months

7 = Other

9 = Unknown

EPIDEMIOLOGIC INFORMATION

Date First Reported to a

Health Department

Month Day Year

Date Case Investigation

Started

Month Day Year

Outbreak Related?

Y = Yes

N = No

U = Unknown 

Epi-Linked?

Y = Yes

N = No

U = Unknown 

Outbreak Name (Name of outbreak this case is associated with)

If patient <12 months old:

What was the mother’s age at infant’s birth: ______________

What was the weight of the infant at birth:

________ lb ________ oz OR ________ kg ________ g

Transmission Setting (Where did this patient acquire pertussis)?

1 = Day Care

2 = School

3 = Doctor’s Office

4 = Hospital Ward

5 = Hospital ER

6 = Hosp. Outpatient Clinic

7 = Home

8 = Work

9 = Unknown

10 = College

11 = Military

12 = Correctional Facility

13 = Church

14 = International Travel

15 = Other

CS218553-A 11/2010

Setting (Outside Household) of Further Documented 

spread From This Case 

Use same codes as for Transmission Settings, except:

 7 = >1 Setting Outside Household

 16 = No Documented Spread Outside Household

Number of Contacts in Any Setting

Recommended Antibiotics 0-998

999 = Unknown 

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DETACH HERE

The information below is epidemiologically imporant, 

but not included on NETSS screens.

Age of the person from whom this patient contracted pertussis

Age 

 999 = Unknown

Age Type

0 = 0-120 years 

1 = 0-11 months 

2 = 0-52 weeks

3 = 0-28 days

9 = Age unknown

Setting In which setting was pertussis acquired?

(Please specify)

In which setting was there secondary spread?

(Please specify)

Day Care

School

Doctor’s Office

Hospital

(Ward/Outpatient/Clinic)

Home

Travel

(International/ Domestic)

Other

Unknown

Name of Contact Birthdate

Relation 

to CasePatientCase? Case ID#

Cough 

Onset Date 

(If Present)

# of 

PCVs*

Date 

of Last 

PCV

Parent’s Name 

and Phone #

(If Applicable)

*PCV=Pertussis-Containing Vaccine

Clinical Case Definition*:

A cough illness lasting >_ 2 weeks with one of the following: paroxysms of coughing, inspiratory “whoop”, or posttussive vomiting, without apparent cause

Case Classification*:

Probable: A case that meets the clinical cas definition, is not laboratory confirmed, and is not epidemiologically linked to a laboratory-confirmed case.

Confirmed: 1) A case that is culture positive, and in which an acute illness of any duration is present, or

 2) a case that meets the clinical case definition and is confirmed by PCR, or

 3) a case that meets the clinical case definition and is epidemiologically linked directly to a case confirmed by either culture or PCR.

*CDC Case Definitions for Infectious Conditions Under Public Health Surveillance. MMWR 1997;46 (No. RR-10):39

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