VARICELLA SURVEILLANCE WORKSHEET Appendix 20-3 

 VARICELLA MMG

Name ______________________________________________________________ State Case I.D. Number 77993-4__________ LAST / FIRST / MIDDLE

Current _________________________________________ Reporting Physician/ ____________________________________ Address NUMBER / STREET / APT. NUMBER Nurse/Hospital/ _________________________________________ Clinic/Lab 48766-0 ____________________________________ PID-11.3 CITY / COUNTY PID-11.9 / STATE PID-11.4 ZIP CODE PID-11.5 ADDRESS 

Telephone: Home ___________________________ Work ____________________ Telephone Number ____________________________________________________________

 AREA CODE + 7 DIGITS AREA CODE + 7 DIGITS AREA CODE + 7 DIGITS 52831-5

Detach here – Transmit only lower portion if sent to CDC

-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

VARICELLA SURVEILLANCE WORSHEET 

 Reported by: State 77966-0_____________ County 77967-8________________

1. Date of Birth PID-11.7

 MONTH DAY YEAR 

2. Current Age 77998-3 7. Date of 

 Report 77995-9 MONTH DAY YEAR 

3. Age Type 7798-3 Years Days Hours 8. Earliest Date 

 Months Weeks Unknown Reported to MONTH DAY YEAR

4. Current SexPID-11.8 Male Female Unknown County 77972-8

 9. Earliest Date 

5. Ethnicity PID-22 Hispanic Not Hispanic Unknown Reported to 77998-3 MONTH DAY YEAR

 State 

6. Race PID-10 American Indian or Alaskan Native 

 Asian Black or African-American 

 Native Hawaiian or Other Pacific Islander

 White Unknown 

 CONDITION 18. Did the patient have a fever? 386661006 Y N U 

 10. Diagnosis 

 Date 77975-1 MONTH DAY YEAR 

 19. Date of 81266-9 

 Fever Onset MONTH DAY YEAR

 11. Illness 11368-8 

 Onset Date MONTH DAY YEAR 

 

 20. Highest measured temperature: 81265-1 __ OBX-6 for °F / °C

 81265-1 CIRCLE ONE

 21. Total number of days with fever: 81264-4 ________ Days

 SIGNS/SYMPTOMS 22. Is patient immunocompromised due 370388006 

 12. Rash Onset to medical condition or treatment? Y N U Date 81268-5 MONTH DAY YEAR (If “yes,” specify INV933 ) ______________________________ 

 13. Rash Generalized Focal Unknown 

 Location 725119006 COMPLICATIONS

 If “focal,” specify dermatome: ___________________ 23. Did the patient visit a healthcare Y N U 

 If “Generalized,” first noted: (check all that apply) provider during this illness? VAR128 

 Face/Head Legs Trunk 24. Did the patient develop any Y N U INV920

 Arms Inside mouth complications that were diagnosed 67187-5 

 Other (specify) ____________________ by a healthcare provider? If “yes”:

 14. How many lesions were there in total? 300579006 Skin/Soft Tissue Infection Y N U INV920 

 <50 50–249 250–499 >500 Cerebellitis/Ataxia Y N U

 15. Character of Lesions (with <50)246206008 Number of lesions __ Encephalitis Y N U

 Macules (flat) present Y N U Number ____ Dehydration Y N U 

 Papules (raised) present Y N U Number ____ Hemorrhagic Condition Y N U 

 Vesicles (fluid) present Y N U Number ____ Pneumonia Y N U

 16. Character of lesions (all categories – 1 to >500) 364637009 How diagnosed: X-Ray MD U 

 Mostly macular/papular Y N U Other complications Y N U 

 Mostly vesicular Y N U (Specify) ______________________________________

 Hemorrhagic INV911 Y N U 25. Was the patient treated with VAR139

 Itchy 418290006 Y N U acyclovir, famvir, or any licensed

 Scabs Y N U antiviral for this illness? If “yes,”

 Crops/waves INV912 Y N U Name of medication: 29303-5 _____________________ 

 17. Did the rash crust? INV913 Y N U Start Date 86948-7

 If “yes,” how many days until all the MONTH DAY YEAR

 lesions crusted over? 81269-3 ________ Days Stop Date 67453-1

 If “no,” how many days did the rash last? ________ Days MONTH DAY YEAR

 26. Was the patient hospitalized 27. Did the patient die from varicella Y N U 

GENERIC MMG

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and 

reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden 

estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-0007

 

Form Approved

OMB No. 0920-0728

Exp. Date 2/28/2011

For Local Use Only

REPORTING SOURCE 

CLINICAL Y=Yes N=No U=Unknown

Varicella Surveillance 8/30/18

GENERIC MMG

INV923
 

 26. Was the patient hospitalized 77974-4 27. Did the patient die from varicella 77978-5 

 for this illness? If “yes”: Y N U or complications (including Y N U

 secondary infection ) associated

 Admission with varicella? If “yes”: Date 8656-1 MONTH DAY YEAR Date of Death PID-29

 Discharge MONTH DAY YEAR 

 Date 8649-6 MONTH DAY YEAR Autopsy performed? Y N U 

 Total duration of stay in hospital 78033-8 ______ Days Cause of death ________________________________ 

 Hospital ________________________________

 Information ________________________________ NOTE: Fill out varicella death worksheet. 

 

 

 L ABORATORY Y=Yes N=No U=Unknown

 

 28. Was laboratory testing done Y N U 34. IgM performed? INV290 Y N U 

 for varicella? LAB630 If “yes”: If “yes”:

 29. Direct fluorescent antibody (DFA) Y N U Type of Capture ELISA Unknown 

 Technique? INV290 IgM Test Indirect ELISA Other ______________

 Date of DFA 

 Date IgM 68963-8 

 DFA Result Positive Pending Specimen Taken MONTH DAY YEAR 

 INV291 Negative Not Done 

 Indeterminate Unknown IgM Test Positive Pending 

 Result INV291 Negative Not Done

 30. PCR specimen? INV290 Y N U Indeterminate Unknown

 Date of PCR Test Result Value LAB628 __________________________

 Specimen MONTH DAY YEAR 

 Source of PCR specimen (check all that apply) 31208-2 35. IgG performed? INV290 Y N U

 Vesicular swab Saliva If “yes”:

 Scab Blood Type of IgG Test:

 Tissue Culture Urine Whole Cell ELISA (specify manufacturer): 

 Buccal Swab Macular Scraping gp ELISA (specify manufacturer)

 Other ____________________________ FAMA Latex Bead Agglutination 

 Other ____________________________________

 31. Culture performed? INV290 Y N U Date of Date of IgG Acute 68963-8 Culture 68963-8 MONTH DAY YEAR

 Specimen MONTH DAY YEAR IgG Acute Positive Pending

 Result INV291 Negative Not Done 

 Culture Positive Pending Indeterminate Unknown 

 Result INV291 Negative Not Done 

 Indeterminate Unknown Test Result Value LAB628 _____________________________ 

 32. Was other laboratory testing INV290 Y N U 36. Were the clinical specimens sent 82314-6 Y N U

 done? If “yes”: to CDC for genotyping (molecular typing?) 

 Specify Tzanck smear If “yes”: 

 Other Test Electron microscopy 

 Date sent for 85930-6

 Date of 68963-8 genotyping MONTH DAY YEAR 

 Other Test MONTH DAY YEAR 

 37. Was specimen sent for strain 82314-6 Y N U 

 Other Lab Positive (results consistent with varicella infection) (wild- or vaccine-type) 

 Test Result Negative identification?

 INV291 Indeterminate Not Done 

 Pending Unknown Strain Type Wild Type Strain 

 Test Result Value LAB628 ________________________ Vaccine Type Strain

 Unknown

 33. Serology performed? INV290 Y N U 

 

MONTH DAY YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME
 

 VACCINE INFORMATION Y=Yes N=No U=Unknown

 

 38. Did the patient receive VAC126 Y N U 39. Number of doses received on or varicella-containing vaccine? after first birthday: VAC129 _________ Doses 

 If “no,” reason: VAC149 40. If patient is ≥6 years old and received one dose on or

 Born outside the United States after 6th birthday but never received second dose, what 

 Lab evidence of previous disease is the reason? Born outside the United States 

 MD diagnosis of previous disease VAC149 Lab evidence of previous disease

 Medical contraindication MD diagnosis of previous disease

 Never offered vaccine Medical contraindication

 Parent/patient forgot to vaccinate Never offered vaccine

Parent/patient refusal Parent/patient forgot to vaccinate

 Parent/patient report of previous disease Parent/patient refusal

Philosophical objection Parent/patient report of previous disease

 Religious exemption Philosophical objection

 Under age for vaccination Religious exemption

 Other ____________________________ Under age for vaccination

Unknown Other _____________________________

 Unknown 

 VACCINATION RECORD 

 Vaccination Date(s) 30952-6 Vaccine Type 30956-7 Manufacturer 30957-5 Lot Number 30959-1

__ __ / __ __ / __ __ __ __

__ __ / __ __ / __ __ __ __

__ __ / __ __ / __ __ __ __

__ __ / __ __ / __ __ __ __

__ __ / __ __ / __ __ __ __

__ __ / __ __ / __ __ __ __

 

 EPIDEMIOLOGIC 

41. Case 77979-3 47. Is this case a healthcare worker? 223366009 Y N U Investigation MONTH DAY YEAR Start Date 48. Is this case part of an outbreak Y N U of 5 or more cases? 77980-1 

42. Has this patient ever been VAR150 Y N U If “yes”: diagnosed with varicella before? If “yes”: Outbreak Name: 77981-9 _____________________________ 

 Age at INV934 49. Case Status: Confirmed

 diagnosis 77990-0 Probable

 Suspect

 Age Type Years Days Not a Case

 OBX-6 for INV934 Months Hours Unknown

 Weeks Unknown

 50. MMWR Week: 77991-8 _______________________________ 43. Previous case Physician/health Care Provider Diagnosed by: Parent/Friend 51. MMWR Year 77992-6_________________________________ VAR152 Other ____________________

 PREGNANT WOMEN

44. Where was the patient born (country)? 78746-5 _______ 52. If the case is female, is/was

45. Is this case epi-linked to another Y N U she pregnant during this Y N U confirmed or probable case? VAR154 varicella illness? 77996-7

 If “yes,” Confirmed varicella case If “yes”:

 Epi-linked to: Probable varicella case 

 VAR155 Herpes Zoster Case Number of weeks gestation at Onset of illness (1-45 weeks): 81270-1 __________ Weeks 

46. Transmission Athletics Hospital Outpatient 

 Setting College Clinic Trimester 1st Trimester

 (Setting of Community Hospital Ward at Onset 2nd Trimester

 Exposure) Correctional Facility International Travel of Illness 3rd Trimester

 81267-7 Daycare Military 81271-9 

 Doctor’s Office Place of Worship 53. General Comments: 77999-1 _________________________

 Home School __________________________________________________

 Hospital ER Work __________________________________________________

 Other __________ Unknown