Appendix 17-3 

Congenital Rubella Syndrome (CRS) Surveillance Worksheet 

NAME ADDRESS (Street and No.) Phone Hospital Record No. 

________________________ _____________________ _____________________________ __________________ ____________________ (last) (first) This information will not be sent to CDC

REPORTING SOURCE TYPE NAME __________________________ 

ם physician ם PH clinic ADDRESS _____________________

ם nurse ם laboratory ZIP CODE _____________________ 

ם hospital ם other clinic PHONE (__ __ __) __ __ __ __ __ __ __ 

ם other source type ____________________________________ 

SUBJECT ADDRESS CITY ___________________________

SUBJECT ADDRESS STATE ___________________________________

SUBJECT ADDRESS COUNTY _______________________

SUBJECT ADDRESS ZIP CODE __ __ __ __ __ 

LOCAL SUBJECT ID _______________________________

CASE INFORMATION

Date of Birth __ __ __ __ __ __ __ __ 

 month day year Sex M=male F=female U=unknown Ethnic Group H=Hispanic/Latino N=Not Hispanic/Latino O=Other _____ U=Unknown 

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 __________________ Other Birth Place __________________ Country of Usual Residence __________________

Age at Case Investigation ______ Age Unit* _____ Reporting County __________________ Reporting State _________

Date Reported __ __ __ __ __ __ __ __

 month day year

Date first Reported to PHD __ __ __ __ __ __ __ __

 month day year

National Reporting Jurisdiction _______

Earliest Date Reported to County __ __ __ __ __ __ __ __ (mm/dd/yyyy) Earliest Date Reported to State __ __ __ __ __ __ __ __ (mm/dd/yyyy)

Case Class Status □Suspected םConfirmed םUnknown םProbable םNot a case Case Investigation Start Date __ __ __ __ __ __ __ __ (mm/dd/yyyy) 

CASE INVESTIGATION

STATUS CODE

Approved Deleted Notified Ready for review Reviewed Unknown

Closed In progress Other (specify)____________ Rejected Suspended

CLINICAL CASE APPRAISAL □ confirmed □ probable □ possible □ infection □ not CRS □ stillbirth 

CASE DETECTION

METHOD

Laboratory report Prenatal testing Provider reported Self-referral Confirmation Date__ __ __ __ __ __ __ __

Other __________ Prison entry screening Routine physical Unknown month day year

CASE

CONFIRMATION

METHOD

 Active surveillance Lab diagnosis No information given

Case outbreak investigation Lab reporting Occupational disease surveillance

Clinical diagnosis Local/state specified Other (specify) _______________________________

Epi-linked Medical records review Provider certified

INFANT HISTORY

Gestational Age (if case-patient <1 year of age) (weeks) Birth State ___________ Birth Weight _________

Birth Weight Unit g=gram kg=kilogram oz=ounce lb=pound _______ Age at Diagnosis ________ Age Unit* at Diagnosis ______

Hospitalized? Y=yes N=no U=unknown Hospital Admit Date __ __ __ __ __ __ __ __

 month day year

Hospital Discharge Date __ __ __ __ __ __ __ __ 

 month day year 

Hospital Stay Duration 0 – 998

 999=unknown days

Illness Onset Date __ __ __ __ __ __ __ __

 month day year 

Illness End Date __ __ __ __ __ __ __ __

 month day year

Illness Duration ______________ Illness Duration Units* _____________ Date of Diagnosis __ __ __ __ __ __ __ __ (mm/dd/yyyy) 

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

INFANT TYPE OF 

COMPLICATIONS

 Y N U Y N U Y N U

Cataract Hearing impairment Patent ductus arteriosus

Congenital glaucoma Low platelets Peripheral pulmonic stenosis

Congenital heart disease Meningoencephalitis Pigmentary retinopathy

Dermal erythropoiesis Microencephaly Purpura

Developmental delay or Mental retardation Neonatal jaundice Radiolucent bone disease

Enlarged liver Other (specify)_____________ Stenosis

Enlarged spleen Other congenital heart disease Unknown

 [Y=yes N=no U=unknown] 

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INFANT DEATH INFORMATION

Date of last evaluation by healthcare provider? __ __ __ __ __ __ __ __

 month day year

Did infant die? Y=yes N=no U=unknown 

At the time of pregnancy cessation, what was the age of the fetus? (weeks ) Deceased Date __ __ __ __ __ __ __ __

 month day year

Death Certificate Primary Cause of Death ___________________ Death Certificate Secondary Cause of Death __________________

MATERNAL HISTORY

Mother’s Birth Country ________________ Mother’s Country of Residence ________________ Mother’s Age at Delivery __________

Mother’s Age at Delivery Units† ____________________ Length of time mother has been in the U.S. _______________ (years)

Did the mother attend a family planning clinic prior to conception? Y=yes N=no U=unknown

The number of children less than 18 years of age living in household during this pregnancy? ___________

Were any of the children living in the household immunized with rubella-containing vaccine? Y=yes N=no U=unknown

The number of children <18 years of age immunized with the rubella vaccine? ________ 

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

MATERNAL CLINICAL INFORMATION

Rash? Y=yes N=no U=unknown Rash Onset Date __ __ __ __ __ __ __ __

 month day year Rash Duration (days)

Fever? Y=yes N=no U=unknown Fever Onset Date __ __ __ __ __ __ __ __

 month day year Fever Duration (days)

Did the mother have lymphadenopathy during the time she was pregnant? Y=yes N=no U=unknown

Did the mother have arthralgia/arthritis during time she was pregnant? Y=yes N=no U=unknown

Did the mother have other clinical illnesses during the time she was pregnant? (specify) ______________________________

Was prenatal care obtained for this pregnancy? Y=yes N=no U=unknown 

Date of first prenatal visit for this pregnancy? __ __ __ __ __ __ __ __

 month day year

Prenatal Care Provider □public sector □private sector □unkown

Did the mother have serological testing prior to this pregnancy? Y=yes N=no U=unknown 

Mother's pre-pregnancy serological test date? __ __ __ __ __ __ __ __

 month day year Pregnancy Outcome ם Live-CRS ם Other ם Unknown

What was the mother's pre-pregnancy serological test interpretation? susceptible immune unknown

Was there a rubella-like illness during this pregnancy? Y=yes N=no U=unknown 

Pregnancy month that rubella-like symptoms appeared? _____ Previous U.S. birth(s)? Y=yes N=no U=unknown

Was rubella physician-diagnosed? Y=yes N=no U=unknown U.S. Birth Dates __ __ __ __ __ __ __ __ __ __ __ __ (yyyy)

If rubella not diagnosed by physician, then by whom? __________________________ Number of births delivered in the US?

Was rubella lab testing performed with this pregnancy? Y=yes N=no U=unknown Number of previous pregnancies? ________ 

Rubella serologically confirmed at time of illness? Y=yes N=no U=unknown Number of total live births? 

 

 

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EXPOSURE INFORMATION

Does the mother know where she might have been exposed to rubella? Y=yes N=no U=unknown 

Did the mother travel outside the U.S. during the first trimester of pregnancy? Y=yes N=no U=unknown

International 

Destination(s) of

Recent Travel 

____________________________

____________________________

Date Left for Travel__ __ __ __ __ __ __ __ 

 month day year

Travel Return Date __ __ __ __ __ __ __ __ 

 month day year

____________________________

____________________________

Date Left for Travel__ __ __ __ __ __ __ __ 

 month day year

Travel Return Date __ __ __ __ __ __ __ __ 

 month day year

Import Status – US-Acquired 1=import-linked case 2=imported virus case 3=endemic case 4=unknown source case 5=other

Was the mother directly exposed to a confirmed case? Y=yes N=no U=unknown Exposure Date __ __ __ __ __ __ __ __

 month day year 

MOTHER’S RELATIONSHIP TO 

CONFIRMED RUBELLA CASE

Brother Friend Mother Other Spouse

Father Grandparent Neighbor Sister Unknown

Country of Exposure __________________________________________ State or Province of Exposure _________________________________

County of Exposure ___________________________________________ City of Exposure _______________________________________________

CASE DISEASE

IMPORTED CODE

Indigenous In state, out of jurisdiction Unknown

International Out of state Yes, imported, but not able to determine source state/country

Imported Country _____________ Imported State _________ Imported County ________________ Imported City _________________

LABORATORY TESTING

VPD Lab Message Reference Laboratory ________________________ VPD Lab Message Patient Identifier _____________________________

VPD Lab Message Specimen Identifier _____________________ Lab testing done to confirm diagnosis? Y=yes N=no U=unknown

Was a specimen sent to CDC? Y=yes N=no U=unknown Was case laboratory confirmed? Y=yes N=no U=unknown

Test

Type

Specimen 

from Date Specimen

Collected

 month day year

Date 

Specimen

Sent to CDC

month day year

Date 

Specimen

Analyzed 

month day year

Test Result

Test Result

Quantitative

Result Units

Test Method

Specimen 

Source Specimen 

Type

Performing

Lab Type 

mother

infant

unknown

IgM

IgM

(capture)

IgG EIA 

(acute)

IgG EIA

(conv)

culture

PCR

other

unknown

IFA

Ab latex

genotype

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TEST RESULTS CODES

P=positive N=negative 

X=not done E=pending 

I=Indeterminate 

NS=no significant rise in titer

PS=significant rise in titer 

U=unknown

SPECIMEN TYPE CODES

1=entire throat 6=entire eye

2=intervertebral space 7=pharyngeal 

3=skin structure 8=other (specify) 

4=mouth region 9=unknown

5=lens of eye 10=nasal cavity

PERFORMING LABORATORY TYPE 

CODES 

1=CDC lab 5=public health lab

2=commercial lab 6=VPD testing lab 

3=hospital lab 8=other (specify) 

4=other clinical lab 9=unknown

GENOTYPE CODES

1a 1F 2A 

1B 1g 2B 

1C 1H 2c 

1D 1I other 

1E 1J unknown 

SPECIMEN SOURCE 

2=blood 3=body fluid 4=BAL 8=cataract 9=CSF 11=DNA sample 15=NP aspirate 16=NP swab 17=NP washings 18=nucleic acid 

19=oral fluid 20=oral swab 21=plasma 22=RNA sample 23=saliva 25=serum 38=urine 40=viral isolate 41=other 42=unknown

 

VACCINATION HISTORY

Vaccinated (was the mother immunized with a rubella vaccine)? Y=yes N=no U=unknown

Number of vaccine doses the mother received on or after her first birthday? 0-6 99=unknown (doses)

Date of mother’s last vaccine dose against this disease prior to illness onset? __ __ __ __ __ __ __ __ (mm/dd/yyyy)

Was mother vaccinated as recommended by ACIP? Y=yes N=no U=unknown If “no” select reason below:

Reason Not Vaccinated Per ACIP 

1 = religious exemption 6 = too young 11 = vaccine record incomplete/unavailable 16 = immigrant 

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 

Source of mother’s vaccine information: 1=mother 2=physician 3=school 4=IIS 8=other ____________________ 9=unknown 

Vaccine

Type 

Vaccination Date 

month day year

Vaccine

Manuf

Vaccine

Lot Number

Vaccine Expiration 

Date 

 

month day year

National 

Drug Code

Vaccination 

Record 

Identifier 

Vaccine Event 

Information 

Source

Vaccine 

Dose 

Number

_____

_____

_____

_____

_____

_____

_____

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

_____

_____

_____

_____

_____

_____

 

 _____

_____________

_____________

_____________

_____________

_____________

_____________

_____________

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

_________

_________

_________

_________

_________

_________

_________

___________

___________

___________

___________

___________

___________

___________

________

________

________

________

________

________

________

____

____

____

____

____

____

____

VACCINE TYPE CODES

03=MMR (measles, mumps, rubella virus) 

04=M/R (measles & rubella virus) 

05=Measles (measles virus) OTH=other 

06=Rubella (rubella virus) 998=no vaccine administered 

07=Mumps (mumps virus) 999=unknown

38=Rubella/mumps (rubella & mumps virus) 

94=MMRV (measles, mumps, rubella, & varicella virus)

 

VACCINE

MANUFACTURER 

CODES

MSD = Merck

OTH = other (specify)

UNK = unknown

VACCINE EVENT INFORMATION SOURCE CODES

 00=new immunization record 

 01=historical information, source unidentified 

 02=historical information, other provider 11=IIS record

 05=historical information, other registry OTH=other (specify) 

 06=historical information, birth certificate UNK=unknown

 07=historical information, school record

 08=historical information, public agency

 09=historical information, patient or parent recall

 10=historical information, patient or parent written record 

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CASE NOTIFICATION

CONDITION 

CODE 10370 Immediate National Notifiable Condition Y=yes N=no U=unknown Legacy Case ID ______________ 

State Case ID _______ Local Record ID ________ Jurisdiction Code ____ Binational Reporting Criteria ___ ___ ___ ___ ___ ___ ___

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

 month day year

Date Report First Electonically Submitted __ __ __ __ __ __ __ __

 month day year

Date of Electronic Case Notification to CDC __ __ __ __ __ __ __ __ month day year MMWR Week ______ MMWR Year ___________

Notification Result Status Final results Record coming as correction Results cannot be obtained

Person Reporting to CDC NAME __________________ (first)

 ________________________________ (last) Person Reporting to CDC Email ____________________ @ _______________

Person Reporting to CDC Phone No. (__ __ __) __ __ __ __ __ __ __

Current Occupation _______________________________________ Current Occupation Standardized ___________________________________

Current Industry __________________________________________ Current Industry Standardized ________________________________________

COMMENTS 

CLINICAL CASE DEFINITION ₸

SUSPECTED

An infant that does not meet the criteria for a probable or confirmed case but who has one of more of the following clinical 

findings: 

• cataracts or congenital glaucoma,

• congenital heart disease (most commonly patent ductus arteriosus or peripheral pulmonary artery stenosis),

• hearing impairment,

• pigmentary retinopathy,

• purpura,

• hepatosplenomegaly,

• jaundice,

• microcephaly,

• developmental delay,

• meningoencephalitis, OR

• radiolucent bone disease

PROBABLE

An infant without an alternative etiology that does not have laboratory confirmation of rubella infection but has at least two of the 

following§: 

o

o

o

o

o

o

cataracts or congenital glaucoma, §

congenital heart disease (most commonly patent ductus arteriosus or peripheral pulmonary artery stenosis),

hearing impairment, OR

o pigmentary retinopathy;

OR 

An infant without an alternative etiology that does not have laboratory confirmation of rubella infection but has at least one or 

more of the following: 

cataracts or congenital glaucoma, § 

congenital heart disease (most commonly patent ductus arteriosus or peripheral pulmonary artery stenosis), 

hearing impairment, OR

o pigmentary retinopathy

AND one or more of the following: 

• purpura,

• hepatosplenomegaly,

• jaundice,

• microcephaly,

• developmental delay,

• meningoencephalitis, OR

• radiolucent bone disease

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CONFIRMED

An infant with at least one symptom (listed above) that is clinically consistent with congenital rubella syndrome; and 

laboratory evidence of congenital rubella infection as demonstrated by: 

• isolation of rubella virus, 

OR

• detection of rubella-specific immunoglobulin M (IgM) antibody, 

OR

• infant rubella antibody level that persists at a higher level and for a longer period than expected from passive 

transfer of maternal antibody (i.e., rubella titer that does not drop at the expected rate of a twofold dilution per 

month), 

OR

● a specimen that is PCR positive for rubella virus.

OTHER CRITERIA

Infection only: 

An infant without any clinical symptoms or signs but with laboratory evidence of infection as demonstrated by: 

• isolation of rubella virus, 

OR

• detection of rubella-specific immunoglobulin M (IgM) antibody, 

OR

• infant rubella antibody level that persists at a higher level and for a longer period than expected from passive 

transfer of maternal antibody (i.e., rubella titer that does not drop at the expected rate of a twofold dilution per 

month), 

OR

• a specimen that is PCR positive for rubella virus.

§In probable cases, either or both of the eye-related findings (cataracts and congenital glaucoma) count as a single 

complication. In cases classified as infection only, if any compatible signs or symptoms (e.g., hearing loss) are identified 

later, the case is reclassified as confirmed.

₸

CSTE Position Statement 09-ID-61 at https://wwwn.cdc.gov/nndss/conditions/rubella-congenital-syndrome/case-definition/2010/

 

 

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