Appendix 20-4 

Varicella 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 ם 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 ם White םNot asked Refused to answer םOther________

Birth Place_____________ 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 __ __ __ __ __ __ __ __

 month day year

Earliest Date Reported to State __ __ __ __ __ __ __ __

 month day year

Case Class Status ם Suspected ם Probable ם Confirmed ם Unknown ם Not a case Case Investigation Start Date __ __ __ __ __ __ __ __

 month day year

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

CLINCAL INFORMATION

Hospitalized? Y=yes N=no U=unknown Hospital Admission 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 __ __ __ __ __ __ __ __

month day year Pregnancy Status Y=yes N=no U=unknown

REASON FOR

HOSPITALIZATION

Varicella related complications Administration of IV treatment Isolation Non-varicella hospitalization 

 Observation Other ___________________________ Severe varicella presentation Unknown 

RashOnset Date __ __ __ __ __ __ __ __

month day year Rash Duration _____ (days) Was the rash generalized? Y=yes N=no U=unknown

BODY REGIONS

OF RASH

(if rash not generalized)

Arm, hand, torso, back 

Head/face with eye involvement

Head/face without eye involvement

Leg

Neck/shoulder

Pelvis/groin/buttocks/hip

Upper mid-abdomen/flank

Other (specify) _____________________

Unknown

Total Number of Lesions <50 50-249 50-500 250-499 >500 Unknown If <50 lesions, how many?

Character of Lesions Maculopapular Vesicular other ___________ unknown Were the lesions hemorrhagic? Y=yes N=no U=unknown

Were the lesions itchy? Y=yes N=no U=unknown Did the lesions appear in crops/waves? Y=yes N=no U=unknown

Did the lesions crust/scab over? Y=yes N=no U=unknown Is patient immunocompromised? Y=yes N=no U=unknown

If patient immunocompromised, then immunocompromised-associated condition or treatment: _____________________ 

Did patient visit a healthcare provider during this illness? Y=yes N=no U=unknown Fever ? Y=yes N=no U=unknown

Fever Onset Date __ __ __ __ __ __ __ __

month day year

Fever Duration _________

(days) Highest Temperature ______ . ___ Temperature Units

 °Cel °F 

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

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_________Unknownם
COMPLICATIONS

TYPE OF

COMPLICATIONS

 Y N U 

cerebellitis/ataxia

dehydration

hemorrhagic condition

 Y N U 

skin/soft tissue infection

other _________________

varicella encephalitis

 Y N U D

pneumonia

Chest X-ray for pneumonia

 Y=yes N=no U=unknown D=not done

Subject’s death from this illness or complications of this illness? Y=yes N=no U=unknown Deceased Date __ __ __ __ __ __ __ __

month day year 

TREATMENT

Antiviral medication? Y=yes N=no U=unknown Treatment Start Date __ __ __ __ __ __ __ __

 month day year

Treatment Duration ______ (days)

Medication received: acyclovir famciclovir valacyclovirOL other __________________ unknown 

LABORATORY TESTING

VPD Lab Message Reference Laboratory

____________________________________

VPD Lab Message Patient Identifier ____________________________________VPD Lab Message Specimen Identifier ___________________________________

Was laboratory testing done to confirm the diagnosis? 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

Test

Result

Date Specimen 

Collected

[mm dd yyyy]

Test Result 

Quantitative

Result 

Units

Specimen 

Source

Date Specimen 

Sent to CDC

[mm dd yyyy]

Date Specimen 

Analyzed

[mm dd yyyy]

Performing 

Laboratory 

Type

IgM __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG

avidity __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG 

(acute) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG 

(conv) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

IgG EIA __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

unspecified

serology __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Culture __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

DFA __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

PCR __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Genotype __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Other __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Strain ID __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Unknown __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Test Results Codes

P=positive N=negative X=not done 

I=Indeterminate E=pending O=other (specify) 

IN=inadequate NS=no significant rise in IgG 

PS=significant rise in IgG U=unknown 

V=vaccine type strain W=wild type strain

Specimen Source Codes

1=blood 8=other (specify) 15=swab (skin lesion) 

2=bronchoalveolar 9=unknown 16=throat swab 

 3=CSF 10=NP washing 17=tissue 

 4=crust 11=saliva 18=urine 

5=lesion 12=scab 19=vesicle fluid 

6=macular scraping 13=serum 20=vesicular swab

7=NP swab 14=skin lesion

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Performing Laboratory Type

1=CDC lab 2=commercial lab

4=other clinical lab 3=hospital lab

5=public health lab 6=VPD testing lab

9=unknown 8=other
 

VACCINATION HISTORY

VACCINATED (has the case-patient ever received varicella-containing vaccine)? 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 

 

month day year

Vaccine

Manuf

Vaccine

Lot Number

Vaccine Expiry 

Date month day year

National 

Drug Code

Vaccination 

Record 

Identifier 

Vaccine Event 

Information 

Source

Vaccine 

Dose 

Number

_____

_____

_____

_____

_____

_____

_____

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__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

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VACCINE TYPE CODES

 

M=measles/mumps/rubella/varicella [MMRV] 

V = varicella vaccine 

O = other (specify) ________________ 

U= unknown

VACCINE

MANUFACTURER CODES

M = Merck

O = other (specify) ______________

U = unknown

VACCINE EVENT INFORMATION SOURCE CODES

 00= new immunization record 

 01= historical information, source unidentified 

 02= historical information, other provider

 05= historical information, other registry OTH= other _________

 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 

REASON NOT VACCINATED PER ACIP 11 = vaccine record incomplete/unavailable 

 1 = religious exemption 6 = too young 12 = parent/patient report of previous disease

 2 = medical contraindication 7 = parent/patient refusal 13 = parent/patient unaware of recommendation

 3 = philosophical objection 8 = other ________________________ 14 = missed opportunity 

 4 = lab evidence of previous disease 9 = unknown 15 = foreign visitor 

 5 = MD diagnosis of previous disease 10 = parent/patient forgot to vaccinate 16 = immigrant

EPIDEMIOLOGIC

Has patient been diagnosed with varicella before? Y=yes N=no U=unknown Age at previous diagnosis?___ Age Units† _____

Previous case was diagnosed by: Parent Physician/Healthcare provider Other_________________ Unknown

If case pregnant at illness onset, weeks gestation? If case pregnant at illness onset, what was trimester of gestation?

Is case-patient a healthcare worker? Y=yes N=no U=unknown Epi-linked to a confirmed or probable case? Y=yes N=no U=unknown 

If epi-linked, type of case: confirmed varicella probable varicella herpes zoster unknown Transmission Mode __________

Transmission

Setting

 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=place of worship 14=international travel 15=community 16=work 17=athletics 

†

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

EXPOSURE

Outbreak Related? Y=yes N=no U=unknown Outbreak Name ________________ COUNTRY of Exposure ___________________

STATE/PROVINCE of Exposure ________ COUNTY of Exposure _______________ CITY of Exposure ____________________

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CASE NOTIFICATION 

Condition Code 10030 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 First Electonically Submitted __ __ __ __ __ __ __ __ month day year 

Date of Electronic Case Notification to CDC __ __ __ __ __ __ __ __ 

month day year MMWR Week ____ MMWR Year ____________ 

Notification Result Status F = Final C = Record is a correction X = Results cannot be obtained 

Person Reporting to CDC __________________________ (first) 

NAME __________________________________ (last) 

Person Reporting to CDC Email __________________ @ ________________ 

Person Reporting to CDC Phone Number (__ __ __) __ __ __ __ __ __ __ 

Current Occupation _____________________________________ Current Occupation Standardized _____________________________________ 

Current Industry ________________________________________ Current Industry Standardized _________________________________________ 

CLINICAL CASE DEFINITION Ŧ

PROBABLE 

An acute illness with 

• Diffuse (generalized) maculo-papulovesicular rash, AND 

• Lack of laboratory confirmation AND 

• Lack of epidemiologic linkage to another probable or confirmed case 

CONFIRMED 

An acute illness with diffuse (generalized) maculo-papulovesicular rash, AND 

● Epidemiologic linkage to another probable or confirmed case, OR 

● Laboratory confirmation by any of the following: 

o Isolation of varicella virus from a clinical specimen, OR 

o Varicella antigen detected by direct fluorescent antibody test, OR 

o Varicella-specific nucleic acid detected by polymerase chain reaction (PCR), OR 

o Significant rise in serum anti-varicella immunoglobulin G (lgG) antibody level by any standard serologic assay. 

Ŧ

CSTE Position Statement 09-ID-68 at https://wwwn.cdc.gov/nndss/conditions/varicella/case-definition/2010 

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