Appendix 8-3 

Measles MMG Measles Surveillance Worksheet GENERIC MMG

Name (Last, First) Hospital Record Number

Address (Street and Number) City PID-11.3 County State Zip Code Phone

Reporting Physician/Nurse/Hospital/Clinic/Lab 48766-0 Address Phone

------------------------------------------ DETACH HERE and transmit only the lower portion if sent to CDC ----------------------------------------------

Measles Surveillance Worksheet

County PID-11.9 State PID-11.4 Zip PID- 11.5

Birth Date PID-7

 

Month Day Year 

Age 

77998-3 

999=unknown

Age Type OBX-6

 0=0-120 years

 1=0-11 months

 2= 0-52 weeks

 3=0-28 days

 9=unknown

Ethnicity PID-22 

 H=Hispanic

 N=not Hispanic

 U=unknown

Race PID-10

 N=Native American/Alaskan Native

 A=Asian/Pacific Islander 

 B=African American 

 W=White U=Unknown

 O=Other 32624-9

Sex PID-8

 M=male

 F=female

 U=unknown

Event Date

 

 Month Day Year 

Event Type

 1=Onset date 4=Reported to County 

 2=Diagnosis date 5=Reported to State 77975-1 or MMWR report date

 3-Lab test date 77973-6

 45375-3 9=Unknown 

Outbreak

Associated

 

 

 Unk=999 

 

Reported 77995-9

 

 

Month Day Year 

Imported 77982-7

 1=Indigenous 

 2=International 

 3=Out of State

 9=Unknown

 

Report 

Status

1=Confirmed

2=Probable

3=Suspect

4=Unknown

CLINICAL DATA

Any Rash? 56831-1 Rash Onset

INV919 Y=yes 81268-5 

 N=No 

 U=Unknown Month Day Year 

Rash Duration 

 81269-3 

 0 – 30 Days

 99 = Unknown 

COMPLICATIONS

Otitis? 67187-5 

 Y=Yes

 N=No INV920

 U=Unknown

Diarrhea? 

 67187-5 

 Y=Yes

 N=No INV920 

 U=Unknown

Pneumonia?

 67187-5 

 Y=Yes

 N=No INV920

 U=Unknown

Encephalitis? 

 67187-5 

 Y=Yes

 N=No INV920

 U=Unknown

Rash Generalized? 

 725119006

 Y=Yes

 N=No 

 U=Unknown

Fever? If Recorded, Highest 

 Measured Temp.

 Y=Yes . 

 N=No INV919 36.0 – 110.0 degrees

 U=Unknown 999.9 = Unknown

Thrombocytopenia?

67187-5 

 Y=Yes

 N=No INV920

 U=Unknown

Death? 77978-5 

 

 Y=Yes

 N=No 

 U=Unknown 

Other Complications?

67187-5 

 Y=Yes

 N=No INV920

 U=Unknown

If Yes, please specify: 

__________________

Cough? 56831-1

 Y=Yes

 N=No INV919

 U=Unknown

Coyza? 56831-1 

 Y=Yes

 N=No INV919

 U=Unknown

Conjunctivitis?

 Y=Yes

 N=No INV919

 U=Unknown

Hospitalized? Days Hospitalized 

77974-4 Y=Yes 0 - 998

 N=No 999=Unknown

 U=Unknown 78033-8

LABORATORY 

Was Laboratory Testing for Measles Done? LAB630

 Y=Yes 

 N=No 

 U=Unknown

VACCINE HISTORY

Vaccinated? (Received measles- If Not Vaccinated, What Was 

containing vaccine?) Y=Yes The Reason? (See Reason

 VAC126 N=No VAC149 Codes Below) U=Unknown

 Date IgM INV290 Result INV291

 Specimen Taken 68963-8 

 

 Month Day Year 

 (See Type and Manuf. Codes Below) 

Vaccination Date 30959-1

Month Day Year 

 

 __________________________________________________________________

 

 Date IgG Acute INV290 Date IgG Convalescent Specimen Taken Specimen Taken

 

 Month Day Year Month Day Year

Result INV291

 P=Significant rise in IgG

 N=No significant rise in IgG

 I=Indeterminate

 E=Pending

 X=Not done

 U=Unknown

Number of doses received 

BEFORE first 1st birthday 

Number of doses received

ON or AFTER 1st birthday

If vaccinated BEFORE 1st birthday

, 

but no doses given ON or AFTER 1st

birthday, what was the reason? 

If received one dose after 1st birthday,

But never received 2nd dose after 1st birthday, 

what was the reason? 

 Page 1 of 2 2009 

 

 

Vaccine

 Type

Vacciine Manuf

 P=Positive E=Pending N=Negative X=Not Done

 I=Indeterminate U=Unknown 

 Lot Number

 Reason Codes

 1=Religious Exemption 7=Parental Refusal

 2=Medical Contraindication 8=Other

 3=Philosophical Objection 9=Unknown

 4=Lab Evidence of Previous Disease

 5=MD Diagnosis of Previous Disease

 6=Under Age for Vaccination 

 

Vaccine 

Type 

Codes

A=MMR

B=Measles

O=Other

 Vaccine 

Manuf. Codes

M=Merck

O=Other

U=Unknown

Other Lab Result

 P=Positive E=Pending

 N=Negative X=Not Done

 I=Indeterminate U=Unknown

Specify Other Lab 

Method: 

11368-8 77972-8

56831-1 81265-1

56831-1

 INV290

 68963-8

 INV291

 VAC128

VAC129

30956-7

30952-6

30957-5

77990-0

 68963-8
EPIDEMIOLOGIC INFORMATION 

 Date First Reported to a Health Department 77970-2

 

 Month Day Year

 Date Case Investigation Started 77979-3 

 

 Month Day Year

Transmission Setting (Where did this case acquire measles?) 81267-7

 1=Day Care 6=Hospital outpatient clinic 11=Military

 2=School 7=Home 12=Correctional Facility

 3=Doctor’s Office 8=Work 13=Church

 4=Hospital Ward 9=Unknown 14=International Travel

 5=Hospital ER 10=College 15=Other

 

Were Age and Setting If Transmission Setting Not Among Those

Verified? (Is age appropriate Listed and Known, What Was the 

for setting, i.e., that is aged 49 Transmission Setting? 

years and in day care, etc,)

 Y=Yes 85700-3 

 N=No 

 U=Unknown

Outbreak Related? 77980-1 If Yes, Outbreak Name Y=Yes 77981-9

 N=No 

 U=Unknown

Source of Exposure For Current Case (Enter State ID if

source was an in-state case; enter Country if source was out- of-state) 

State 77993-4 Country 77984-3

Epi-Linked to Another

Confirmed or Probable 

Case? INV217 Y=Yes 

 N=No 

 U=Unknown

Is Case Traceable Within 

2 Generations to anINV286

International Import? 

 Y=Yes 

 N=No 

 U=Unknown

 Indicates epidemiologically important 

 items not yet on NETSS screen 

Contact Information: (For statistical health department use) 

Mother’s Name Father’s Name

Phone

...................................................................................................................... Detach Here ..............................................................................................................................

The information below is epidemiologically important, but not included on NETSS screens

Activity History For 18 Days Before Rash Onset and 7 Days After Rash Onset

Day -18

Day -17

Day -16

Day -15

Day -14

Day -13

Day -12

Day -11

Day -10

Day -9

Day -8

Day -7

Day -6

Day -5

Day -4

Day -3

Day -2

Day -1

Day 0 (Rash Onset)

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Clinical Case Definition: 

A generalized rash lasting > 3 days, a temperature > 101.0° F (>38.3° C), and cough, coryza, or conjunctivitis.

Case Classification: 

Suspected: Any febrile illness accompanied by rash. 

Probable: A case that meets the clinical case definition, has noncontributory or no serologic or virologic testing, and is not epidemiologically 

linked to a confirmed case. Confirmed: A case that is laboratory confirmed or that meets the clinical case definition and is epidemiologicallylinked to a confirmed case. A laboratory-confirmed case does not need to meet the clinical case definition.

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