Tetanus Surveillance Worksheet Appendix 18

NAME (Last, First) Hospital Record No.

Address (Street and No.) City County Zip Phone

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

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CDC NETSS ID County State Zip

Birth Date

Month Day Year

Age

Unknown= 999 

Age Type

0 = 0-120 years

1 = 0-11 months

2 = 0-52 weeks

3 = 0-28 days

9 = Unknown

Race

N = Native Amer./Alaska Native W = White A = Asian/Pacific Islander O = Other B = African American U = Unknown

Ethnicity

H = Hispanic

N = Not Hispanic

U = Unknown 

Sex

M = 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

6 = Unknown

Reported

Month Day Year

Imported

1 = Indigenous

2 = International

3 = Out of State

9 = Unknown

Report Status

1 = Confirmed

2 = Probable

3 = Suspect

9 = Unknown 

 

 Year

: ____________

HiSTory

CS106190 02/09

 

 

Date

Month Day

Year of Onset 

Occupation 

History of Military Service

(Active or Reserve)?

Y = Yes

N = No

U = Unknown 

Year of Entry into

Military Service

Tetanus Toxoid Vaccination 

History Prior to Tetanus Disease

(Exclude Doses Received Since Acute Injury)

0 = Never 

1 = 1 dose 

2 = 2 doses 

3 = 3 doses

4 = 4+ doses

9 = Unknown

Years Since 

Last Dose

0 - 98

99 = Unknown

a CliniCal DaT

Acute Wound 

Identified? 

Y = Yes

N = No

U = Unknown 

Date Wound Occurred

Month Day Year

Principal Anatomic Site

1 = Head

2 = Trunk

3 = Upper Extremity

4 = Lower Extremity

9 = Unspecified

Work Related?

Y = Yes

N = No

U = Unknown

Environment

0 = Home 

1 = Other Indoors

2 = Farm / Yard 

3 = Automobile

4 = Other Outdoors

9 = Unknown

Circumstances

Principal Wound Type

1 = Puncture

2 = Stellate Laceration

3 = Linear Laceration

4 = Crush

5 = Abrasion 6 = Avulsion

7 = Burn

8 = Frostbite

9 = Compound Fracture

10 = Other (e.g. with cancer) 

Specify

11 = Surgery

12 = Animal Bite

13 = Insect Bite/Sting

14 = Dental

15 = Tissue Necrosis

99 = Unknown

Wound 

Contaminated?

Y = Yes

N = No

U = Unknown 

Depth of Wound

1 = 1 cm. or less

2 = more than 1 cm.

9 = Unknown 

Signs of Infection?

Y = Yes

N = No

U = Unknown 

Devitalized, Ischemic, or 

Denervated Tissue Present?

Y = Yes

N = No

U = Unknown 

MeDiCal Care Prior To onSeT

Was Medical Care Obtained 

For This Acute Injury

Y = Yes

N = No

U = Unknown 

Tetanus Toxoid (TT/Td/Tdap) 

Administered Before Tetanus Onset

Y = Yes

N = No

U = Unknown 

If Yes, How Soon After Injury?

1 = < 6 Hours 

2 = 7 - 23 Hours 

3 = 1 - 4 Days 

4 = 5 - 9 Days

5 = 10 - 14 Days

6 = 15+ Days

9 = Unknown

Wound Debrided Before

Tetanus Onset

Y = Yes

N = No

U = Unknown 

If Yes, Debrided How Soon 

After Injury

1 = < 6 Hours 

2 = 7 - 23 Hours 

3 = 1 - 4 Days 

4 = 5 - 9 Days

5 = 10 - 14 Days

6 = 15+ Days

9 = Unknown

Tetanus Immune Globulin

(TIG) Prophylaxis Received

Before Tetanus Onset

Y = Yes

N = No

U = Unknown

If Yes, TIG Given How Soon 

After Injury?

1 = < 6 Hours 

2 = 7 - 23 Hours 

3 = 1 - 4 Days 

4 = 5 - 9 Days

5 = 10 - 14 Days

6 = 15+ Days

9 = Unknown

Dosage 

(Units)

0 - 998 

999 = Unknown

Associated Condition 

(If no Acute Injury)

1 = Abscess

2 = Ulcer

3 = Blister

4 = Gangrene

5 = Cellulitis

6 = Other Infection

7 = Cancer

8 = Gingivitis

88 = None

99 = Unknown

Describe Condition: Diabetes?

Y = Yes

N = No

U = Unknown

If Yes, InsulinDependent?

Y = Yes

N = No

U = Unknown 

Parenteral Drug 

Abuse?

Y = Yes

N = No

U = Unknown

Describe Condition:

CliniCal CourSe

Type of Tetanus Disease

1 = Generalized

2 = Localized

3 = Cephalic

4 = Unknown

TIG Therapy Given 

After Tetanus Onset Y = Yes

N = No

U = Unknown 

If Yes, How Soon After Illness Onset?

1 = < 6 Hours

2 = 7 - 23 Hours 

3 = 1 - 4 Days 

4 = 5 - 9 Days

5 = 10 - 14 Days

6 = 15+ Days

9 = Unknown

Dosage 

(Units)

0 - 998 

999 = Unknown

Days Hospitalized

0 - 998 

999 = Unknown

Days In ICU

0 - 998 

999 = Unknown

Days Received Mechanical Ventilation

0 - 998 

999 = Unknown

Outcome One Month After Onset?

R = Recovered

C = Convalescing

D = Died 

If Died, Date of Death

Month Day Year

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Tetanus Surveillance Worksheet

NAME (Last, First) Hospital Record No.

Address (Street and No.) City County Zip Phone

Reporting Physician/Nurse/Hospital/Clinic/Lab Phone Address Phone Ld Mother’s A

in Years

99 = Unknown

Mother’s 

Birth Date

Month Day Year

Date Mother’s 

Arrival in U.S.

Month Day Year

Mother’s Tetanus Toxoid Vaccination 

History PRIOR to Child’s Disease

(Known Doses Only)

1 = 1 dose

2 = 2 doses

0 = Never 3 = 3 doses

4 = 4+ doses

9 = Unknown

Years Since Mother’s 

Last Dose

0 - 98 

99 = Unknown

Child’s Birthplace

1 = Hospital

2 = Home

3 = Other

9 = Unknown

Birth Attendant(s)

1 = Physician

2 = Nurse

3 = Licensed Midwife

4 = Unlicensed Midwife

5 = Other

9 = Unknown

Other Birth Attendant(s) 

(If Not Previously Listed)

Other Comments?

Y = Yes

N = No

U = Unknown 

Reporter’s Name Title

Institution Name Phone Number Date Reported

Month Day Year

Clinical Case Definition*:

Acute onset of hypertonia and/or painful muscular contractions (usually of the muscles of the jaw and neck) and generalized muscle spasms

Case Classification*:

Confirmed: A clinically compatible case, as reported by a health-care professional.

Notes/Other Information:

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

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