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Appendi 10-4 

Mumps urveillance Worksheet 

NAME ADD ESS (Street and No.) Phone Hospital ecord No. 

________________________ _____________________ _____________________________ __________________ ____________________ 

(last) (first) 

This information will not be sent to CDC 

 EPO TING SOU CE TYPE NAME __________________________ 

ם physician ם clinic PH ADD ESS ________________________ 

ם nurse ם laboratory ZIP CODE ________________________ 

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

ם other source type ______________________________________ 

SUBJECT ADD ESS CITY _______________________ 

SUBJECT ADD ESS STATE ______________________ 

SUBJECT ADD ESS COUNTY ___________________ 

SUBJECT ADD ESS ZIP CODE ___ ___ ___ ___ ___ 

LOCAL SUBJECT ID ____________________________ 

CASE INFO MATION 

Date of Birth __ __ __ __ __ __ __ __ 

mon h day year Sex M=male F=female U=unknown Ethnic Group H=Hispanic/La ino N=No Hispanic/La ino O=O her _____ U=Unknown 

 ace ם American Indian/Alaskan Na ive םAsian םBlack/African American םNa ive Hawaiian/Pacific Islander םWhi e ם ed No ask ם Refused o answer םO her ם Unknown 

Country of Birth __________________ Other Birth Place __________________ Country of Usual esidence __________________ 

Age at Case Investigation _____ Age Unit* _____ eporting County __________________ eporting State _________ 

Date eported __ __ __ __ __ __ __ __ 

mon h day year 

Date First eported to PHD __ __ __ __ __ __ __ __ 

mon h day year National eporting Jurisdiction ______ 

Earliest Date eported to County __ __ __ __ __ __ __ __ 

mon h day year 

Earliest Date eported to State __ __ __ __ __ __ __ __ 

mon h day year 

Case Class Status □Suspec ed םConfirmed םUnknownם a case No םProbable Case Investigation Start Date __ __ __ __ __ __ __ __ 

mon h day year 

Case Investigation Status Code ם approved ם closed □ dele ed ם progress in ם no ified ם o her ם ______rejec ed ם reviewed ם suspended ם unknown

Detection Method □ prena al es ing □ prison en ry □ provider repor □ rou ine physical □ self-referral □ o her _____________ □ unknown 

CLINICAL INFO MATION 

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

mon h day year 

Hospital Discharge Date __ __ __ __ __ __ __ __ 

mon h day year 

Hospital Stay Duration 0 – 998 

999=unknown days 

Illness Onset Date __ __ __ __ __ __ __ __ 

mon h day year 

Illness End Date __ __ __ __ __ __ __ __ 

mon h day year 

Illness Duration ______ Illness Duration Units* _____ Date of Diagnosis __ __ __ __ __ __ __ __ 

mon h day year 

Pregnancy Status 

Y=yes N=no U=unknown 

SIGNS and SYMPTOMS Y N U Y N U 

Paro i is Fever 

Sublingual salivary gland swelling Jaw pain 

Submandibular salivary gland swelling Muscle pain 

Headache Tiredness 

Loss of appe i e O her _____________ 

Y=yes N=no U=unknown 

Parotitis  bila eral  unila eral  o her  unknown 

SALIVA Y GLAND SWELLING 

ONSET DATE __ __ __ __ __ __ __ __ 

mon h day year 

DU ATION _______ (days 

COMPLICATIONS 

Y N U Y N U 

Deafness Orchi is 

Encephali is Pancrea i is 

Mas i is O her _________________ 

Meningi is Unknown 

Oophori is Dea h 

Y=yes N=no U=unknown 

Type of 

Deafness 

 permanen  emporary 

 o her ___________  unknown 

Date of Fever Onset 

__ __ __ __ __ __ __ __ 

mon h day year 

Highest Temperature 

________ . ____ 

Deceased Date __ __ __ __ __ __ __ __ 

mon h day year 

Temperature Units ◦ Cel ◦

F 

*UNITS a=year h=hour mo=mon h w=week d=day min=minu e s=second OTH=o her UNK=unknown 

SEP 2021 
 

 

 

 

 

Test 

Type 

IgM 1 

IgM 2 

IgG 1 

acu e 

Test 

 esult 

Test esult 

Quantitative 

 esult 

Units 

Specimen 

Source 

(Type) 

Date Specimen

Collected 

(mm/dd/yyyy) 

 __ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ 

Specimen 

Analyzed Date 

(mm/dd/yyyy) 

Date Specimen 

Sent to CDC 

(mm/dd/yyyy) 

Performing 

Laboratory 

Type 

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 

IgG 

conv __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 

IgG 

single 

culture 

genotype 

PC 1 

PC 2 

other 

unspecified 

serology 

molecular 

typing 

unknown 

__ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_________________________________________ __________________________________________ __________________________________________ 

LABO ATO Y TESTING 

VPD Lab Message eference Laboratory VPD Lab Message Patient Identifier VPD Lab Message Specimen Identifier 

Was there laboratory testing done to confirm the diagnosis? Y=Yes N=No U=Unknown 

Was case laboratory confirmed? Y=yes N=no U=unknown 

Test esults 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 

VT=vaccine type strain 

WT=wild type strain 

1=bacterial isolate 8=cataract 15=NP aspirate 22= NA 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=lumg 35=swab (internal nose) 42=unknown 

Was a specimen sent to CDC for testing? Y=yes N=no U=unknown 

Specimen Source Codes 

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 

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 mon h day year 

 

 6 = hospi al ou pa ien 

7 = home 11 = mili ary 

 8 = o her _______________________ 

9 = unknown 12 = correc ional facili y 

10 = college 13=church 

 14 = in erna ional ravel 

15 = communi y 

16 = work 

 17 = a hle ics 

 

 

 

  prena al es ing 

  o her _____________________

  self-referral  unknown 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IMPORTATION AND EXPOSURE INFORMATION 

Imported Code 1=Indigenous 2=in erna ional 3=in s a e, ou of jurisdic ion 4=ou of s a e 5=impor ed, unable o de emine source 9=unknown 

Imported Country ______________ Imported State ___ Imported County _________________ Imported City ___________________ 

IMPO T STATUS: Did onset occur within 12-25 days of entering the U.S. following any travel? Y=yes N=no U=unknown 

IMPO T STATUS: US-Acquired 1=impor -linked case 2=impor ed virus case 3=endemic case 4=unknown source case 5=o her __________ 

INTE NATIONAL 

DESTINATIONS 

OF ECENT 

T AVEL 

____________________ 

____________________ Travel eturn Date __ __ __ __ __ __ __ __ 

 mon h day year 

Length of time in the U.S since last 

travel: _____________________ 

____________________ 

____________________ Travel eturn Date __ __ __ __ __ __ __ __ 

 mon h day year 

† UNITS LENGTH of TIME in the U.S. 

______________ 

†UNITS a=year h=hour mo=mon h w=week d=day min=minu e s=second OTH=o her UNK=unknown 

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

Outbreak related? Y=yes N=no U=unknown Outbreak Name __________ Investigation Start Date __ __ __ __ __ __ __ __ 

Country of Exposure _____ State/Province of Exposure _____ County of Exposure ________ City of Exposure________ 

T ANSMISSION SETTING 

1 = day care 

2 = school 

3 = doc or’s office 

4 = hospi al ward 

5 = hospi al ER 

Transmission Mode _______________________________ 

Detection Method 

 rou ine physical exam

 prison en ry screenin

 provider repor ed 

g 

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

VACCINATION HISTO Y 

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

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

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

Vaccine 

Type Vaccination Date 

mon h day year 

Vaccine 

Manuf 

Vaccine 

Lot Number 

Vaccine Expiration 

Date mon h day year 

National 

Drug Code 

Vaccination 

 ecord 

Identifier 

Vaccine Event 

Information 

Source 

Vaccine 

Dose 

Number 

_____ 

_____ 

_____ 

_____ 

__ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ 

_____ 

_____ 

_____ 

_____ 

_____________ 

_____________ 

_____________ 

_____________ 

__ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ 

__ __ __ __ __ __ __ __ 

_________ 

_________ 

_________ 

_________ 

___________ 

___________ 

___________ 

___________ 

________ 

________ 

________ 

________ 

____ 

____ 

____ 

____ 

VACCINE TYPE CODES VACCINE EVENT INFO MATION SOU CE CODES 

 EASON NOT VACCINATED PE ACIP 

1 = religious exemp ion 6 = oo young 11 = vaccine record incomple e/unavailable 

2 = medical con raindica ion 7 = paren /pa ien refusal 12 = paren /pa ien repor of previous disease 

3 = philosophical objec ion 8 = o her ______________________ 13 = paren /pa ien unaware of recommenda ion 

4 = lab evidence of previous disease 9 = unknown 14 = missed oppor uni y 16 = immigran 

5 = MD diagnosis of previous disease 10 = paren /pa ien forgo o vaccina e 15 = foreign visi or 17 = vaccine no available 

VACCINE HISTO Y COMMENTS 

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A=MMR =rubella 

B=mumps virus vaccine M=rubella/mumps 

M =M/R MM=MMRV 

M=measles virus vaccine O=o her 

U=unknown N=no vaccine adminis ered 

VACCINE 

MANUFACTU E 

CODES 

M = Merck 

 O = o her 

 U = unknown 

00= new immuniza ion record 

01= his orical informa ion, source uniden ified 

02= his orical informa ion, o her provider 

05= his orical informa ion, o her regis ry 

06= his orical informa ion, bir h cer ifica e 

07= his orical informa ion, school record 

 08= his orical informa ion, public agency 

 09= his orical informa ion, pa ien /paren recall 

 10= his orical informa ion, pa ien /paren 

 wri en record 

 UNK= unknown 

 OTH= o her 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CASE NOTIFICATION 

Condition Code 10180 Immediate National Notifiable Condition Y=yes N=no U=unknown Legacy Case ID _____________ 

State Case ID _________ Local ecord ID ________ Jurisdiction Code ____ Binational eporting Criteria ___ ___ ___ ___ ___ ___ ___ 

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

mon h day year 

Date eport First Electonically Submitted __ __ __ __ __ __ __ __ 

mon h day year 

Date of Electronic Case Notification to CDC -- -- -- -- -- -- -- -- mon h day year MMW Week ____ MMW Year ________________ 

Notification esult Status Final resul s Record coming as correc ion Resul s canno be ob ained 

Person eporting to CDC __________________________ (firs ) 

NAME _______________________________ (las ) 

Person eporting to CDC Email ____________________ @ ____________ 

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

Current Occupation _____________________________________ Current Occupation Standardized (NIOCCS code) __________________ 

Current Industry __________________________________________ Current Industry Standardized (NIOCCS code) _____________________ 

COMMENTS 

CLINICAL CASE DEFINITION § 

SUSPECTED 

▪ Paro i is, acu e salivary gland swelling, orchi is, or oophori is unexplained by ano her more likely diagnosis, 

O 

▪ A posi ive lab resul wi h no mumps clinical symp oms (wi h or wi hou epidemiological-linkage o a confirmed or probable 

case). 

P OBABLE 

▪ Acu e paro i is or o her salivary gland swelling las ing a leas 2 days, or orchi is or oophori is unexplained by ano her more 

likely diagnosis, in: 

o A person wi h a posi ive es for serum an i-mumps immunoglobulin M (IgM) an ibody, O 

o A person wi h epidemiologic linkage o ano her probable or confirmed case or linkage o a group/communi y defined by 

public heal h during an ou break of mumps. 

CONFI MED 

▪ A posi ive mumps labora ory confirma ion for mumps virus wi h reverse ranscrip ion polymerase chain reac ion (RT-PCR) or 

cul ure in a pa ien wi h an acu e illness charac erized by any of he following: 

o Acu e paro i is or o her salivary gland swelling, las ing a leas 2 days 

o Asep ic meningi is 

o Encephali is 

o Hearing loss 

o Orchi is 

o Oophori is 

o Mas i is 

o Pancrea i is 

§CSTE Posi ion S a emen 11-ID-18 a h ps://cdn.ymaws.com/www.cs e.org/resource/resmgr/PS/11-ID-18.pdf 

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