Appendix 8-5 

MEASLES MMG Measles Surveillance Worksheet GENERIC MMG

 

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 M=male F=female U=unknown

PID-8

Ethnic Group H=Hispanic/Latino N=Not Hispanic/Latino O=Other _____ U=Unknown

 PID-22 

Race םAmerican Indian/Alaskan Native םAsian םBlack/African American םNative Hawaiian/Pacific Islander םWhite םNot asked ם Refused to answer םOther___ ם Unknown

Country of Birth 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 __ __ __ __ __ __ __ __ (mm/dd/yyyy) Earliest Date Reported to State __ __ __ __ __ __ __ __ (mm/dd/yyyy) 

*UNITS a=year d=day mo=month w=week OTH=other UNK=unknown

CASE CLASS STATUS Suspected Probable Confimed Not a case Unknown Date Confirmed __ __ __ __ __ __ __ __

 INV162 month day year

CASE INVESTIGATION

STATUS CODE INV109

Approved Deleted Notified Ready for review Reviewed Unknown

Closed In progress Other ___________ Rejected Suspended

CASE DETECTION

METHOD INV159

Laboratory reported Prison entry screening Routine physical exam Self-referral

Prenatal testing Provider reported Other _________________ Unknown

CASE INV161

CONFIRMATION

METHOD

Active surveillance Epi-linked Local/state specified Occupational disease surveillance

Case/outbreak investigation Lab diagnosis Medical records review Other (specify) _____________________

Clinical diagnosis Lab reporting No information given Provider certified 

CLINICAL INFORMATION

Hospitalized? Y=yes N=no U=unknown

 77974-4 

Hospital Admit 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 __ __ __ __ __ __ __ __

 77975-1 month day year

Pregnancy Status 77996-7

Y=yes N=no U=unknown 

SIGNS and 

SYMPTOMS 

 56831-1 

 Y N U Onset Date Duration

Rash

81268-5

__ __ __ __ __ __ __ __ month day year__ __ __ Was rash generalized?

Y=yes N=no U=unknown 

Age at rash onset? 

Age Type Units 

Fever

81266-9

__ __ __ __ __ __ __ __ month day year

Highest Measured 81265-1

Temperature ▪

Temperature °Cel

Units OBX-6 for 81265-1 °F

 Y N U Y N U Y N U 

Cough Conjunctivitis Other _____________________________

Coryza Unknown Y=Yes N=No U=Unknown INV919

COMPLICATIONS

 67187-5 

 Y N U Y N U Y N U

Croup Otitis Pneumonia Chest X-ray 

for Pneumonia

INV923

 Positive

 Negative

 Not Done

 Unknown

Diarrhea Thrombocytopenia Unknown

Encephalitis Other (specify) ________ Died? 

Hepatitis Y=Yes N=No U=Unknown INV920 Date of death? PID-29 __ __ __ __ __ __ __ __ (mm/dd/yyyy)

Mar 2019 Page 1 of 4

PID-10 32624-9

77978-5

 

725119006

81269-3 85949-6

77972-8 77973-6

77990-0

OBX-6 for 85949-6
 

 

 

LABORATORY TESTING

VPD Lab Message Reference Laboratory

LAB143 ___________________________________

VPD Lab Message Patient Identifier

 LAB598 ___________________________________

VPD Lab Message Specimen Identifier

 LAB125 __________________________________

Was there 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

Test Result 

Quantitative

LAB628

Result 

Units

LAB115

Specimen 

Source (Type)

Specimen 

Source (Site)

Date Specimen

Collected

68963-8 

mm/dd/yyyy)

Date Specimen

Sent to CDC

85930-6 

(mm/dd/yyyy)

Specimen

Analyzed Date

45375-3 

(mm/dd/yyyy)

Performing

Laboratory 

Type

82771-7

IgM EIA 

Capture __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgM EIA __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG EIA

Acute __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG EIA

Conv __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IF 

IgG Ab __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Culture __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Genotype

60422-3 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

PCR __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Ag by IFA __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

OTHER __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

unspec

serology __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

unknown __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Test Results Codes

P=positive N=negative 

X=not done I=Indeterminate 

E=pending O=other

NS=no significant rise in titer 

PS=significant rise in titer 

U=unknown

Specimen Source (Type) Codes

1=bacterial isolate 8=cataract 15=NP aspirate 22=RNA 29=lavage 36=throat swab 

2=blood 9=CSF 16=NP swab 23=saliva 30=stool 37=tissue 

3=body fluid 10=crust 17=NP washing 24=scab 31=swab 38=urine 

4=BAL 11=DNA 18=nucleic acid 25=serum 32=swab (skin lesion) 39=vesicle fluid 

5=buccal smear 12=lesion 19=oral fluid 26=skin lesion 33=swab (nasal sinus) 40=viral isolate 

6=buccal swab 13=macular scraping 20=oral swab 27=specimen 34=vesicular swab 41=other 

7=capillary blood 14=microbial isolate 21=plasma 28=lung 35=swab (internal nose) 42=unknown 

Genotype 

Sequence 

A B2 B3 C1 C2 D2 D3 D4 D5 D6 D7 D8 

D9 D10 G2 G3 H1 H2 other unknown

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 4 

INV164 82314-6

31208-2 66746-9
IMPORTATION AND EXPOSURE INFORMATION

Imported Code 1=indigenous 2=international 3=in state, out of jurisdiction 4=out of state 5=imported, unable to detemine source 9=unknown

77982-7

Imported Country INV153 ________ Imported State ___ INV154Imported County INV156 ___________ Imported City ___________________

 INV155

IMPORT STATUS: Did onset occur within 7-21 days of entering the U.S. following any travel? Y=yes N=no U=unknown

IMPORT STATUS: US-Acquired 1=import-linked case 2=imported virus case 3=endemic case 4=unknown source case 5=other __________ 

Traceable to international import? Y=yes N=no U=unknown Was case a healthcare provider? Y=yes N=no U=unknown

INTERNATIONAL 

DESTINATIONS 

OF RECENT 

TRAVEL 82764-2

____________________

____________________ Travel Return Date __ __ __ __ __ __ __ __ 

 TRAVEL08 month day year

Length of time in the U.S since last

travel: DEM225 _____________________ 

____________________

____________________

Travel Return Date __ __ __ __ __ __ __ __ 

 TRAVEL08 month day year

UNITS† LENGTH of TIME in the U.S. 

______________ OBX-6 for DEM225

Is this case epi-linked to another confirmed or probable case? INV217 Y=yes N=no U=unknown 

Outbreak related? Y=yes N=no U=unknown 77980-1 

Outbreak Name __________ 77981-9

Investigation Start Date __ __ __ __ __ __ __ __

77979-3 month day year 

Country of Exposure _____ 77984-3 

State/Province of Exposure _____ 77985-0

County of Exposure ________ 77987-6 

City of Exposure________ 77986-8

TRANSMISSION SETTING 81267-7 Transmission Mode 77989-2 _______________________ 1 = day care 4 = hospital ward 7 = home 10 = college 13 = place of worship 16 = work

2 = school 5 = hospital ER 8 = other _____________ 11 = military 14 = international travel 17 = athletics

3 = doctor’s office 6 = hospital outpatient 9 = unknown 12 = correctional facility 15 = community

Age & setting verified: does the age of the case match or make sense for the listed transmission setting? Y=yes N=no U=unknown

†UNITS a=year h=hour mo=month w=week d=day min=minute s=second OTH=other UNK=unknown

VACCINATION HISTORY

Vaccinated (has the case-patient ever received a vaccine against this disease)? VAC126 Y=yes N=no U=unknown 

Number of vaccine doses received before first birthday? VAC128 0-6 99 = unknown (doses)

Was case-patient vaccinated 

as recommended by the ACIP?

 Y=yes 

 N=no U=unknown 

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

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

Date of last vaccine dose prior to illness onset: VAC142 __ __ __ __ __ __ __ __ (mm/dd/yyyy) 

Vaccine

Type 

30956-7 

Vaccination Date

30952-6 

 

month day year

Vaccine

Manuf

30957-5

Vaccine

Lot Number

30959-1 

Vaccine Expiration 

Date VAC109 

month day year

National 

Drug Code

VAC153 

Vaccination 

Record 

Identifier 

VAC102

Vaccine Event 

Information 

Source

VAC147

Vaccine 

Dose 

Number

30973-2 

_____

_____

_____

_____

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

_____

_____

_____

_____

_____________

_____________

_____________

_____________

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

_________

_________

_________

_________

___________

___________

___________

___________

________

________

________

________

____

____

____

____

VACCINE TYPE CODES

A=MMR R=rubella 

B=mumps virus vaccine RM=rubella/mumps

MR=M/R MM=MMRV

M=measles virus vaccine O=other 

U=unknown N=no vaccine administered 

VACCINE

MANUFACTURER 

CODES

M = Merck

 O = other

 U = unknown

VACCINE EVENT INFORMATION SOURCE CODES

00=new immunization record 08=historical information, public agency

01=historical information, source unspecified 09=historical information, patient/parent recall 

02=historical information, other provider 10=historical information, patient/parent’s 

05=historical information, other registry written record

06=historical information, birth certificate 11=immunization information system (IIS)

07=historical information, school record UNK=unknown OTH=other

 Page 3 of 4

 INV293

INV286 223366009

INV516

85700-3

VAC129

 VAC148

 
REASON NOT VACCINATED PER ACIP VAC149 

1 = religious exemption 6 = too young 11 = vaccine record incomplete/unavailable

2 = medical contraindication 7 = parent/patient refusal 12 = parent/patient report of previous disease 

3 = philosophical objection 8 = other ______________________ 13 = parent/patient unaware of recommendation

4 = lab evidence of previous disease 9 = unknown 14 = missed opportunity

5 = MD diagnosis of previous disease 10 = parent/patient forgot to vaccinate 15 = foreign visitor 16 = immigrant 

VACCINE HISTORY COMMENTS VAC133 

CASE NOTIFICATION

Condition Code 10140 OBR-31

Immediate National Notifiable Condition Y=yes N=no U=unknown

 77965-2 Legacy Case ID 77997-5 _______

State Case ID 77993-4 ___ Local Record ID OBR-3 ____ Jurisdiction Code ____ Binational Reporting Criteria 77988-4 ___ ___ ___ ___ ___

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

 77994-2 month day year

Date Report 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 Final results Record coming as correction 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 No. 74548-9 (__ __ __) __ __ __ __ __ __ __

Current Occupation 85658-3 _______________________________ Current Occupation Standardized 85659-1 _________________________

Current Industry 85078-4 __________________________________ Current Industry Standardized 85657-5 _____________________________

COMMENTS 77999-1 

CLINICAL CASE DEFINITION ₸

An acute illness characterized by: 

▪ Generalized, maculopapular rash lasting ≥3 days; and

▪ Temperature ≥101°F or 38.3°C; and

▪ Cough, coryza, or conjunctivitis.

PROBABLE

In the absence of a more likely diagnosis, an illness that meets the clinical description with: 

 ▪ No epidemiologic linkage to a laboratory-confirmed measles case; and 

 ▪ Noncontributory or no measles laboratory testing.

CONFIRMED 

An acute febrile rash illness§ with:

▪ Isolation of measles virus¶ from a clinical specimen; or

▪ Detection of measles-virus specific nucleic acid¶ from a clinical specimen using polymerase chain reaction; or

▪ IgG seroconversion§ or a significant rise in measles immunoglobulin G antibody¶ using any evaluated and validated method; or

▪ A positive serologic test for measles immunoglobulin M antibody¶#; or

▪ Direct epidemiologic linkage to a case confirmed by one of the methods above.

§ Temperature does not need to reach ≥101°F/38.3°C and rash does not need to last ≥3 days.

¶ Not explained by MMR vaccination during the previous 6-45 days.

# Not otherwise ruled out by other confirmatory testing or more specific measles testing in a public health laboratory.

Case Classification Comment: CDC does not request or accept reports of suspect cases so this category is no longer needed for national 

reporting purposes.

₸CSTE Position Statement 11-ID-18 at https://wwwn.cdc.gov/nndss/conditions/measles/case-definition/2013/

Page 4 of 4

77969-4