Measles Surveillance Worksheet Appendix 8 

NAME (Last, First) Hospital Record No. 

Address (Street and No.) City County Zip Phone 

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

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Measles Surveillance Worksheet 

CS106190

N INFORMATIO EPIDEMIOLOGIC 

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 

Ethnicity Race Sex 

H = Hispanic N = Native Amer./Alaskan Native W = White M = Male 

N = Not Hispanic A = Asian/Pacific Islander O = Other F = Female 

U = Unknown B = African American U = Unknown U = Unknown 

Outbreak e Report Status Event Dat Event Type Imported 4 = Reported to County Associated Reported 1 = Indigenous 1 = Confirmed 1 = Onset Date 5 = Reported to State or 2 = International 2 = Probable 2 = Diagnosis Date MMWR Report Date 3 = Out of State 3 = Suspect 3 = Lab Test Done 9 = Unknown 9 = Unknown 9 = Unknown Month Day Year Unk = 999 Month Day Year 

Any Rash? Rash Onset Rash Duration Otitis? Diarrhea? Pneumonia? Encephalitis? Y = Yes 0 - 30 Days Y = Yes Y = Yes Y = Yes Y = Yes N = No 99 = Unknown U = Unknown S 

N = No N = No N = No N = No 

A 

Month Day Year U = Unknown U = Unknown N

U = Unknown U = Unknown 

DAT

If Recorded, Highest 

CLINICAL 

Measured Temp. 

TIO

Rash Generalized? Fever? 

CA

Thrombocytopenia? Death? Other Complications? 

Y = Yes Y = Yes . Y = Yes Y = Yes Y = Yes 

N = No N = No N = No N = No N = No 36.0 -110.0 degrees U = Unknown U = Unknown U = Unknown U = Unknown U = Unknown 999.9 = Unknown OMPLI

Cough? Coryza? Conjunctivitis? C

Hospitalized? Days Hospitalized If Yes, Please Specify: 

Y = Yes Y = Yes Y = Yes Y = Yes 0 - 998 

N = No N = No N = No N = No 999 - Unknown 

U = Unknown U = Unknown U = Unknown U = Unknown 

Was Laboratory Testing For Measles Done? 

Y = Yes 

N = No 

U = Unknown 

Date IgM Result 

Specimen Taken P = Positive E = Pending 

N = Negative X = Not Done 

I = Indeterminate U = Unknown 

Month Day Year 

YR TO

Date IgG Acute Date IgG Convalescent 

Specimen Taken 

RA

Specimen Taken 

O AB L

Month Day Year Month Day Year 

Other Lab Result 

Result P = Positive E = Pending 

P = Significant Rise in IgG N = Negative X = Not Done 

N = No Significant Rise in IgG I = Indeterminate U = Unknown 

I = Indeterminate 

E = Pending Specify Other Lab Method: X = Not Done 

U = Unknown 

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

containing vaccine?) Y = Yes The Reason? (See Reason N = No Codes Below) U = Unknown 

(See Type and Manuf. Codes Below) Vaccine Vaccine Vaccination Date 

Month Day Year Type Manuf Lot Number 

Y HISTOR VACCINE Number of doses received Reason Codes 

BEFORE 1st birthday 1 = Religious Exemption 7 = Parental Refusal 

2 = Medical Contraindication 8 = Other 

Number of doses received 3 = Philosophical Objection 9 = Unknown 

ON or AFTER 1st birthday 4 = Lab. Evidence of Previous Disease 

5 = MD Diagnosis of Previous Disease 

If vaccinated BEFORE 1st birthday, 6 = Under Age For Vaccination 

but no doses given ON or AFTER 1st 

birthday, what was the reason? Vaccine Type Codes Vaccine Manuf. Codes 

A = MMR M = Merck 

If received one dose after 1st birthday, B = Measles O = Other 

but never received 2nd dose after 1st O = Other U = Unknown 

U = Unknown birthday, what was the reason? 

Date First Reported to a Health Department 

Month Day Year 

Transmission Setting (Where did this case acquire measles?) 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. aged 49 years Transmission Setting? and in day care, etc.) 

Y = Yes 

N = No 

U = Unknown 

Date Case Investigation Started 

Month Day Year 

Outbreak Related? If Yes, Outbreak Name Y = Yes 

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 US; enter State if source was out-ofstate) 

Epi-Linked to Another Is Case Traceable Within 2 

Confirmed or Probable Generations to an International 

Case? Y = Yes Y = Yes 

 ? 

N = No Import N = No U = Unknown U = Unknown 

Indicates epidemiologically important 

items not yet on NETSS screen Page 1 of 2 
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Contact Information: (For statistical health department use) 

Mother’s Name Father’s Name 

Phone 

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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 epidemiologically-linked to 

a confirmed case. A laboratory-confirmed case does not need to meet the clinical case definition. 

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