Name (Last, First) Hospital Record Number

Address (Street and Number) City County State Zip Code Phone

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

County State Zip Code

Birth Date

hh hh hhhh 

Month Day Year

Event Date

hh hh hhhh 

Month Day Year

Event Type

h

Reported

hh hh hhhh 

Month Day Year

Import Status

h h

Report Status

h

Age

hhh 

999 = Unknown

Age Type

h 

Ethnicity

h 

Meningitis?

h 

Deafness?

h 

Orchitis?

h 

Encephalitis?

h 

Hospitalized? Days Hospitalized

h hhh

Death?

h 

Other 

Complications?

h 

If Yes, please specify

Race

h 

Sex

h 

Appendix 10-2

Mumps Surveillance Worksheet

Mumps Surveillance Worksheet

0 = 0-120 years

1 = 0-11 months

2 = 0-52 weeks

3 = 0-28 days

9 = Age unknown

1 = Onset Date

2 = Diagnosis Date

3 = Lab Test Date

4 = Reported to County

5 = Reported to State or 

MMWR Report Date

9 = Unknown

H = Hispanic

N = Not Hispanic

U = Unknown

Y = Yes

N = No

U = Unknown

Y = Yes

N = No

U = Unknown

Y = Yes

N = No

U = Unknown

999 = Unknown

Y = Yes

N = No

U = Unknown

Y = Yes

N = No

U = Unknown

Y = Yes

N = No

U = Unknown

Y = Yes

N = No

U = Unknown

N = Native American / Alaskan Native

A = Asian / Pacific Islander

B = African American

W = White

O = Other

U = Unknown

1 = U.S.-acquired

2 = International 

Import

1 = Import-linked

2 = Imported Virus

3 = Endemic

4 = Unknown 

Source

M = Male

F = Female

U = Unknown

1 = Confirmed

2 = Probable

3 = Suspect

4 = Unknown

CLINICAL DATA LABORATORY

COMPLICATIONS EPIDEMIOLOGIC

Parotitis 

(opposite 2nd molars)?

h

Notes

Was Laboratory Testing Done for Mumps?

h

Date First Reported to a Health Department

hh hh hhhh 

Month Day Year

Source of Exposure for Current Case (Enter State ID if source was 

an in-state case; enter Country if source was out of U.S.; enter State 

if source was out-of-state)

Date Case Investigation Started

hh hh hhhh 

Month Day Year

Epi-linked to Another Confirmed or Probable Case?

h

Outbreak Related? If Yes, Outbreak Name

h

Transmission Setting (Where did this person acquire mumps?)

h

If Other, Specify Transmission Setting

Were Age and Setting Verified? (Is age appropriate for setting?)

h

Date Serologic (IgG) Specimens Taken

IgG (acute) 

hh hh hhhh 

Month Day Year

Test Used 

Units Reported 

IgG (convalescent) 

hh hh hhhh 

Month Day Year

Test Used 

Units Reported 

Single IgG Specimen Only

hh hh hhhh 

Month Day Year

Test Used 

Units Reported 

Date Serologic (IgM) Specimens Taken

IgM (1) hh hh hhhh 

Month Day Year

IgM (2) hh hh hhhh 

Month Day Year

Other Lab Results

PCR hh hh hhhh 

Month Day Year

Culture hh hh hhhh 

Month Day Year

Salivary Gland Swelling (including parotitis) 

Onset Duration

hh hh hhhh hhh

Month Day Year

Submandibular? Sublingual?

h h

Jaw Pain? 

Y = Yes h N = No

U = Unknown

Y = Yes

N = No

U = Unknown

Y = Yes

N = No

U = Unknown

Y = Yes

N = No

U = Unknown

Y = Yes

N = No

U = Unknown

Y = Yes

N = No

U = Unknown

Y = Yes

N = No

U = Unknown

1-998 = Number of Days

999 = Unknown

h Unilateral 

h Bilateral

CS106190

Result

h

Result

h

Result

h

h

h

h

Result Codes

P = Significant 

rise in IgG

I = Indeterminate

N = No significant 

rise in IgG

E = Pending

X = Not Done

U = Unknown

Result Codes

P = Positive

I = Indeterminate

N = Negative

E = Pending

X = Not Done

U = Unknown

DETACH HERE and transmit only the lower portion if sent to CDC

1 = Day Care

2 = School

3 = Doctor’s Office

4 = Hospital Ward

5 = Hospital ER

6 = Hospital Outpatient Clinic

7 = Home

8 = Work

9 = Unknown

10 = College

11 = Military

12 = Correctional Facility

13 = Church

14 = International Travel

15 = Other

Page 1 of 2

Y = Yes

N = No

U = Unknown
Vaccinated? (Received 

mumps-containing vaccine?)

h

Notes (History of natural mumps disease?)

Vaccination Date Vaccine Type Manufacturer Lot Number

hh hh hhhh h h hhhhhhhhhh 

hh hh hhhh h h hhhhhhhhhh 

hh hh hhhh h h hhhhhhhhhh 

hh hh hhhh h h hhhhhhhhhh 

Number of Doses Received After 1st Birthday

h

If Not Vaccinated, What Was the Reason?

h

VACCINE HISTORY

Y = Yes

N = No

U = Unknown

DETACH HERE and transmit only the lower portion if sent to CDC

Vaccine Type 

Codes

A = MMR

B = Mumps

O = Other

U = Unknown

1 = Religious Exemption

2 = Medical 

Contraindication

3 = Philosophical 

Objection

4 = Lab. Evidence of 

Previous Disease

5 = MD Diagnosis of 

Previous Disease

6 = Under Age for 

Vaccination

7 = Parental Refusal

8 = Other

9 = Unknown

9 = Unknown

Vaccine 

Manufacturer 

Codes

M = Merck

O = Other

U = Unknown

Page 2 of 2

Notes/Other information