Appendix 11-5

 Pertussis Surveillance Worksheet 

Generic MMG Pertussis_V1.0_MMG_R1_20180504

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 Country of Birth 78746-5 _ Other Birth Place 21842-0 _ Country of Usual Residence 77983-5 

Race םAmerican Indian/Alaskan Native םAsian םBlack/African American םNative Hawaiian/Pacific Islander םWhite םNot asked ם Refused to answer םOther 32624-9 ם Unknown

Ethnic Group H=Hispanic or Latino N=Not Hispanic/Latino O=Other __________ U=Unknown Sex PID-8 M=male F=female U=unknown

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 77972-8 __ __ __ __ __ __ __ __ (mm/dd/yyyy) Earliest Date Reported to State 77973-6 __ __ __ __ __ __ __ __(mm/dd/yyyy)

Case Class Status 77990-0 םSuspected ם Probable םConfirmed םUnknown ם Not a case Case Investigation Start Date __ __ __ __ __ __ __ __ 

 77979-3 month day year

Case Detection Method INV159 ם prenatal testing ם prison entry ם provider report ם routine physical ם self-referral □ other ___________ □

unknown 

Case Investigation Status Code INV109 םapproved םclosed םdeleted םin progress םnotified ם other_____ ם rejected םreviewed םsuspended םunknown

CLINICAL INFORMATION

 Illness Onset Date __ __ __ __ __ __ __ __

 11368-8 month day year

Illness End Date __ __ __ __ __ __ __ __

 77976-9 month day year

Illness Duration _____

77977-7

Duration Units* ______

 OBX-6 for 77977-7

Hospitalized? Y=yes N=no U=unknown

77974-4

Hospital Admission Date __ __ __ __ __ __ __ __ 

 8656-1 month day year

Hospital Discharge Date __ __ __ __ __ __ __ __

 8649-6 month day year

Duration of Hospital Stay 0 – 998 _____ 

 78033-8 999=unknown (days) 

Date of Diagnosis __ __ __ __ __ __ __ __

 77975-1 month day year

Pregnancy Status Y=yes N=no U=unknown

77996-7

SIGNS AND SYMPTOMS 56831-1

 Y N U Y N U

Apnea Post-tussive vomiting

Cough Whoop

Cyanosis Other (specify) ________

Paroxysmal cough ________________________

 INV919 Y=yes N=no U=unknown 

 COMPLICATIONS 67187-5

 Y N U

Encephalopathy

Seizures

Other ___________________

 NV920 Y=yes N=no U=unknown 

Cough Onset Date 85932-2 __ __ __ __ __ __ __ __ (mm/dd/yyyy) Age at Cough Onset 85934-8 Age Unit* OBX-6 for 85943-8 _____

Total Cough Duration 85933-0 (days) Was there a cough at patient’s final interview? PRT008 Y=yes N=no U=unknown

Date of Final Interview __ __ __ __ __ __ __ __

 INV555 month day year Subject died? 77978-5 Y=yes N=no U=unknown Deceased Date __ __ __ __ __ __ __ __

 PID-29 month day year 

Chest X-Ray for Pneumonia INV923 P=positive N=negative X=not done U=unknown Were antibiotics given? Y=yes N=no U=unknown

 INV559 

*UNITS OBX-6 a=year d=day h=hour min=minute mo=month s=second wk=week UNK=unknown

 

 PID-10

 PID-22

AUG 2020 Page 1 of 5

 
TREATMENT

First Antibiotic Received 29303-5

Date Treatment Initiated __ __ __ __ __ __ __ __

86948-7 month day year

Treatment Duration (days) 

 67453-1 

ANTIBIOTIC(S) GIVEN

 1 = amoxicillin 2 = amoxicillin-potassium clavulanate combination 3 = ampicillin 4 = azithromycin 5 = ceftriaxone 6 = cefuroxime 

7 = ciprofloxacin 8 = other ________________________________ 9 = unknown 10 = clarithromycin 11 = doxycycline 12 = erythromycin 

13 = none 14 = penicillins 15 = trimethoprim-sulfamethoxazole 16 = tetracycline 

Second Antibiotic Received 29303-5Date Treatment Initiated __ __ __ __ __ __ __ __

 86948-7 month day year

Treatment Duration (days) 

 67453-1 

LABORATORY INFORMATION

VPD Lab Message Reference Laboratory

LAB143 _______________________________

VPD Lab Message Patient Identifier

 LAB598 _________________________________

VPD Lab Message Specimen Identifier

 LAB125 ______________________________

Was Laboratory Testing Done to Confirm 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

Date Specimen

Collected

68963-8 month day year

Test Result 

Quantitative

LAB628

Result 

Units

LAB115

Specimen 

Source

31208-2 

Date Specimen

Sent to CDC

85930-6 month day year

Specimen

Analyzed Date

OBX-19 month day year

Performing 

Laboratory 

Type

82771-7

IgA

29672-3 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgM

29673-1 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG

(acute) LAB635

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

IgG

(conv)

LAB636

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

IgG

EIA 29659-0

(unspecified) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG

toxin

85684-9

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

culture

549-6 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

DFA

550-4 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

PCR

23826-1 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 

genotype

LAB634 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

other test 

type LAB608 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ 

unspecified

serology 

LAB707

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

unknown

LAB609 __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Lab Test Interpretation Codes INV291

BP=Bordetella parapertussis

BS=Bordetella species

P=positive N=negative E=pending

X=not done 

S=significant rise in titer

NS=no significant rise in titer 

I=Indeterminate Q=equivocal 

O=other (specify) U=unknown

Specimen Source Codes 31208-2 

1=bacterial isolate 10=cataract 19=nasopharyngeal isolate 28=scab 37=nasal sinus

 2=blood 11=CSF 20=nasopharygeal swab 29=serum 38=vesiculaswab 

3=body fluid 12=lesion 21=nasopharygeal washing 30=skin lesion 39=internal nose 

4=bronchoalveolar lavage 13=microbial isolate 22=nucleic acid 31=specimen 40=throat 

5=buccal smear 14=crust 23=oral fluid 32=lung 41=tissue 

 6=buccal swab 15=DNA 24=oral swab 33=lavage 42=urine 

7=capillary blood 16=lesion 25=plasma 34=stool 43=vesicle fluid 

8=other (specify) 17=macular scraping 26=RNA 35=swab 44=viral isolate 

9=unknown 18=microbial isolate 27=saliva 36=skin lesion swab 

Performing Laboratory 1=CDC lab 2=commercial lab 3=hospital lab 4=other clinical lab 5=public health lab 

Type 82771-7 6=VPD testing lab 8=other (specify) 9=unknown 

 Page 2 of 5 

INV164 82314-6
 VACCINATION HISTORY INFORMATION

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

Was the subject vaccinated per ACIP recommendations? VAC148 Y=yes N=no U=unknown

Number of doses against this disease received prior to illness onset: 82745-1 0 - 6 99=unknown (doses)

Date of last dose against this disease 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 Expiry 

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 30956-7 

W=DTP whole cell X=Tdap

A=DTaP unspecified K=DTaP-IPV

R=DTaP 5 pertussis V=DTaP-IPV-HepB

H=DTap-Hib N=DTaP-IPV-Hib

D=DT or Td H=DTaP-IPV-HIB-HEPB historical

T=DTP-Hib B=DTaP,IPV,Hib,HepB

P=pertussis only O=other (specify) 

 

VACCINE 

MANUFACTURER CODES 30957-5

C = Sanofi Pasteur 

L=Wyeth 

S=GlaxoSmithKline

M=Massachusetts Health 

Department

I=Michigan Health Department

N=North American Vaccine

O = other (specify)

U = unknown

VACCINE EVENT INFORMATION SOURCE CODES VAC147 

 00= new immunization record 

 01= historical information, source unidentified 

 02= historical information, other provider

 05= historical information, other registry

 06= historical information, birth certificate OTH= other

 07= historical information, school record UNK= unknown 

 08= historical information, public agency

 09= historical information, patient or parent recall

 10= historical information, patient or parent written record

Reason Not Vaccinated Per ACIP VAC149

1 = religious exemption 5 = MD diagnosis of previous disease 9 = unknown 13 = parent/patient unaware of recommendation 

2 = medical contraindication 6 = too young 10 = parent/patient forgot to vaccinate 14 = missed opportunity

3 = philosophical objection 7 = parent/patient refusal 11 = vaccine record incomplete/unavailable 15 = foreign visitor 

4 = lab evidence of previous disease 8 = other _______________ 12 = parent/patient report of previous disease 16 = immigrant 

EXPOSURE

Epi-linked to confirmed Case? Y=yes N=no U=Unknown 

INV927 

Outbreak related? Y=yes N=no U=unknown

77980-1

Outbreak Name

77981-9 

__________________

Country of Exposure ___ 77984-3 

State/Province of Exposure ______

77985-0 

County of Exposure ______ 77987-6 

City of Exposure ______________

77986-8

IMPORTATION

Imported Code 77982-7 1=Indigenous 2=international 3=in state, out of jurisdiction 4=out of state 5=imported, unable to detemine source 9=unknown 

Imported Country INV153 __________ Imported State INV154 ___ Imported County INV156 ______ Imported City INV155____________

TRANSMISSION

SETTING 

81267-7 

 1 = day care 2 = school 3 = doctor’s office 4 = hospital ward 5 = hospital ER 

 6 = hospital outpatient 7 = home 8 = other _______________ 9 = unknown 

10 = college 11 = military 12 = correctional facility 13 = place of worship

14 = international travel 15 = community 16 = work 17 = athletics 

Transmission

Mode 77989-2 

________________ 

 

Page 3 of 5 
EPIDEMIOLOGIC INFORMATION

Mother’s age at infant’s birth (if case <1yr old): 

85724-3

Did mother receive Tdap (if case <1yr old)? Y=yes N=no U=unknown

MTH172

When was Tdap administered? MTH173 prior to pregnancy during pregnancy postpartum other __________________ unknown

Date Tdap Administered __ __ __ __ __ __ __ __

MTH174 month day year

Gestational Age

(if case <1yr old) weeks 

18185-9

Infant Birth Weight

(if case <1 yr old) 

56056-5

Birth Weight Units OBX-6 for 56056-5 

g=gram lb=pound Kg=kilogram oz=ounce

Was case-patient a healthcare provider at onset of illness? 223366009 Y=yes N=no U=unknown

Transmission Setting of Further Spread INV561 

 1 = day care 2 = school 3 = doctor’s office 4 = hospital ward 5 = hospital ER 6 = hospital outpatient clinic 7 = home

 8 = other _______________ 9 = unknown 10 = college 11 = military 12 = correctional facility 13 = church 

14 = international travel 15 = work 16 = athletics 17 = community 18 = no documented spread outside 19 = setting outside household 

One or more suspected sources of infection? PRT070 Y=yes N=no U=unknown Number of Suspected Sources PRT071

Suspected 

Source

Age

PRT074

Age Unit† 

OBX-6 for 

PRT074

Sex

PRT076

Relationship 

to Case

PRT077

Cough Onset Date

PRT088

month day year 

Number of 

Contacts

Recommended 

Prophylaxis

INV562

____________

Relationship Codes PRT077

bro=brother ngh=neighbor 

fth=father oth=other (specify)

fnd=friend sis=sister 

grp=grandparent spo=spouse

mth=mother unk=unknown

Sex Codes PRT076

F=female M=male U=unk

Source 1 __ __ __ __ __ ___ __ __ __ __ __ __ __ __ __ __ __

Source 2 __ __ __ __ __ ___ __ __ __ __ __ __ __ __ __ __ __

Source 3 __ __ __ __ __ ___ __ __ __ __ __ __ __ __ __ __ __

†

Units OBX-6 a=year d=day mo=month wk=week unk=unknown

CASE NOTIFICATION

Condition 

Code OBR-31 10190 Immediate National Notifiable Condition 77965-2 Y=yes N=no U=unknown Legacy Case ID _________

77997-5 

State Case ID ________

77993-4

Local Record ID _______

OBR-3

Jurisdiction Code ____

77969-4

Binational Reporting Criteria ___ ___ ___ ___ ___ ___ ___

77988-4

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

77994-2 month day year

Date 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 _______

Current Occupation (type of work case-patient does) 

 85658-3 ________________________________

Current Occupation Standardized (NIOCCS code)

85659-1 __________________________

Current Industry (type of business or industry in which casepatient works) 85078-4 ___________________________________Current Industry Standardized (NIOCCS code) 

85657-5 _____________________________

Person Reporting to CDC Name ____________________ (first)

 74549-7 ________________________________ (last) 

Person Reporting to CDC Email 74547-1 ________________ @ ______________

Person Reporting to CDC Phone Number 74548-9 (__ __ __) __ __ __ __ __ __ __

COMMENTS 77999-1

 

 Page 4 of 5 

 

 

 

 

 
Page 5 of 5 

CLINICAL CASE DEFINITIONŦ

PROBABLE

● In the absence of a more likely diagnosis, illness meeting the clinical criteria

OR 

● Illness with cough of any duration, with 

  At least one of the following signs or symptoms: 

o Paroxysms of coughing; or

o inspiratory whoop; or

o Post-tussive vomiting, or

o Apnea (with or without cyanosis) 

 AND 

  Contact with a laboratory confirmed case (epidemiological linkage)

CONFIRMED

Acute cough illness of any duration, with 

● Isolation of B. pertussis from a clinical specimen OR 

● PCR positive for B. pertussis

Ŧhttps://wwwn.cdc.gov/nndss/conditions/pertussis/case-definition/2020/