For Local Use Only VARICELLA SURVEILLANCE WORKSHEET

Name State Case I.D. Number

LAST / FIRST / MIDDLE
Current Reporting Physician/
NUMBER / STREET / APT. NUMBER
Address Nurse/Hospital/
Clinic/Lab
CITY / COUNTY / STATE ZIP CODE ADDRESS
Telephone: Home Work Telephone Number
AREA CODE + 7 DIGITS AREA CODE + 7 DIGITS AREA CODE + 7 DIGITS

Detach here — Transmit only lower portion if sent to CDC

VARICELLA suRVEILLAnCE woRkshEEt Form Approved

OMB No. 0920-0728
Exp. Date 2/28/2011
Reported by: State County

REPoRtInG souRCE
1. Date of Birth cc cc cccc
MONTH DAY YEAR
7. Date of cc cc cccc
2. Current Age ccc Report MONTH DAY YEAR

3. Age Type c Years c Days c Hours 8. Earliest Date cc cc cccc

c Months c Weeks c Unknown
Reported to MONTH DAY YEAR
County
4. Current Sex c Male c Female c Unknown 9. Earliest Date cc cc cccc
5. Ethnicity c Hispanic c Not Hispanic c Unknown Reported to MONTH DAY YEAR
State
6. Race c American Indian or Alaska Native
c Asian c Black or African-American
Department of Health and Human Services
c Native Hawaiian or Other Pacific Islander Centers for Disease Control and Prevention
c White c Unknown

CLInICAL Y=Yes n=no u=unknown

ConDItIon 18. Did the patient have a fever? cY c N c U

10. Diagnosis cc cc cccc 19. Date of cc cc cccc
Date MONTH DAY YEAR
Fever Onset MONTH DAY YEAR

11. Illness cc cc cccc 20. Highest measured temperature: °F / °C

Onset Date MONTH DAY YEAR CIRCLE ONE

21. Total number of days with fever: Days

sIGns/sYMPtoMs
22. Is patient immunocompromised due c Y c N c U
12. Rash Onset cc cc cccc to medical condition or treatment?
Date MONTH DAY YEAR
(If yes, specify)
13. Rash c Generalized c Focal c Unknown
Location CoMPLICAtIons
If “Focal,” specify dermatome:
23. Did the patient visit a healthcare cY c N c U
If “Generalized,” first noted: (check all that apply) provider during this illness?
c Face/Head c Legs c Trunk
24. Did the patient develop any cY cN cU
c Arms c Inside Mouth complications that were diagnosed
c Other (specify) by a healthcare provider? If “yes”:
14. How many lesions were there in total? Skin/Soft Tissue Infection cY cN cU
c <50 c 50–249 c 250–499 c >500 Cerebellitis/Ataxia cY cN cU
Encephalitis cY cN cU
15. Character of Lesions (with <50) Number of lesions:
Dehydration cY cN cU
Macules (flat) present: c Y c N cU Number:
Hemorrhagic Condition cY cN cU
Papules (raised) present: c Y c N cU Number: Pneumonia cY cN cU
Vesicles (fluid) present: c Y c N cU Number: How diagnosed: c X-ray c MD c U
16. Character of Lesions (all categories—1 to >500) Other Complications cY cN cU
Mostly macular/papular c Y c N c U
Mostly vesicular cY c N c U (Specify)
Hemorrhagic cY c N c U
25. Was the patient treated with cY c N c U
Itchy cY c N c U acyclovir, famvir, or any licensed
Scabs cY c N c U antiviral for this illness? If “yes,”
Crops/waves cY c N c U Name of medication:
17. Did the rash crust? cY c N c U Start Date cc cc cccc
If “yes,” how many days until all the MONTH DAY YEAR

lesions crusted over? Days Stop Date cc cc cccc

If “no,” how many days did the rash last? Days MONTH DAY YEAR
CS118977

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)
Varicella Surveillance 05/09/05
26. Was the patient hospitalized cY c N c U 27. Did the patient die from varicella cY c N c U
for this illness? If “yes”: or complications (including
secondary infection) associated
Admission cc cc cccc with varicella? If “yes”:
Date MONTH DAY YEAR

cc cc cccc Date of cc cc cccc

Discharge
Date MONTH DAY YEAR
Death MONTH DAY YEAR

Autopsy performed? cY c N c U
Total duration of stay in the hospital: Days
Cause of death
Hospital
Information NAME
NOTE: Fill out varicella death worksheet.

LAB
LABooRA
RAto
toRRY Y=Yes n=no u=uY=Y
nknown
es n=no u=unknown

28. Was laboratory testing done cY c N c U 34. IgM performed? cY c N c U

for varicella? If “yes”: If “yes”:
29. Direct fluorescent antibody (DFA) cY c N c U Type of c Capture ELISA c Unknown
technique? IgMTest c Indirect ELISA c Other
Date of DFA cc cc cccc Date IgM cc cc cccc
MONTH DAY YEAR Specimen MONTH DAY YEAR
Taken
DFA Result c Positive c Pending
c Negative c Not Done IgM Test c Positive c Pending
Result c Negative c Not Done
c Indeterminate c Unknown
c Indeterminate c Unknown
30. PCR specimen? cY c N c U
Test Result Value
Date of PCR cc cc cccc
Specimen MONTH DAY YEAR 35. IgG performed? cY c N c U
If “yes”:
Source of PCR specimen: (check all that apply)
c Vesicular Swab c Saliva Type of IgG Test:
c Scab c Blood c Whole Cell ELISA (specify manufacturer):
c Tissue Culture c Urine
c Buccal Swab c Macular Scraping c gp ELISA (specify manufacturer):
c Other
c FAMA c Latex Bead Agglutination
PCR Result c Positive c Not Done c Other
c Negative c Pending
c Indeterminate c Unknown Date of cc cc cccc
c Other IgG-Acute MONTH DAY YEAR

31. Culture performed? cY c N c U IgG-Acute c Positive c Pending

Result c Negative c Not Done
Date of cc cc cccc
Culture MONTH DAY YEAR c Indeterminate c Unknown
Specimen
Test Result Value
Culture c Positive c Pending
Result Date of IgG- cc cc cccc
c Negative
c Indeterminate
c Not Done
c Unknown
Convalescent MONTH DAY YEAR

IgG-Conv. c Positive c Pending

32. Was other laboratory testing cY c N c U Result c Negative c Not Done
done? If “yes”:
c Indeterminate c Unknown
Specify c Tzanck smear
Other Test Test Result Value
c Electron microscopy
36. Were the clinical specimens sent c Y c N c U
Date of cc cc cccc to CDC for genotyping (molecular typing)?
Other Test MONTH DAY YEAR If “yes”:
Other Lab c Positive (results consistent with varicella infection) Date sent for cc cc cccc
Test Result c Negative genotyping MONTH DAY YEAR

c Indeterminate c Not Done 37. Was specimen sent for strain cY c N c U

c Pending c Unknown (wild- or vaccine-type) identification?
Test Result Value Strain Type c Wild Type Strain
c Vaccine Type Strain
33. Serology performed? cY c N c U
c Unknown
 VACCInE InFoRMAtIon Y=Yes n=no u=unknown

38. Did the patient receive cY c N c U 39. Number of doses received on or

varicella-containing vaccine? after first birthday: Doses
If “no,” reason:
40. If patient is >=6 years old and received one dose on or
c Born outside the United States after 6th birthday but never received second dose, what
c Lab evidence of previous disease is the reason?
c MD diagnosis of previous disease c Born outside the United States
c Medical contraindication c Lab evidence of previous disease
c Never offered vaccine c MD diagnosis of previous disease
c Parent/patient forgot to vaccinate c Medical contraindication
c Parent/patient refusal c Never offered vaccine
c Parent/patient report of previous disease c Parent/patient forgot to vaccinate
c Philosophical objection c Parent/patient refusal
c Religious exemption c Parent/patient report of previous disease
c Under age for vaccination c Philosophical objection
c Other c Religious exemption
c Unknown c Other
c Unknown

VACCInAtIon RECoRD

Vaccination Date(s) Vaccine Type Manufacturer Lot Number

__ __ / __ __ /__ __ __ __

__ __ / __ __ /__ __ __ __

__ __ / __ __ /__ __ __ __

__ __ / __ __ /__ __ __ __

__ __ / __ __ /__ __ __ __

EPIDEMIoLoGIC Y=Yes n=no u=unknown

41. Case cc cc cccc 47. Is this case a healthcare worker? cY c N c U

Investigation MONTH DAY YEAR
48. Is this case part of an outbreak cY c N c U
Start Date
of 5 or more cases?
42. Has this patient ever been cY c N c U If “yes”:
diagnosed with varicella before?
If “yes”: Outbreak Name:
Age at ccc 49. Case Status: c Confirmed
Diagnosis
c Probable
Age Type c Years c Days c Suspect
c Months c Hours c Not a Case
c Weeks c Unknown c Unknown
43. Previous case c Physician/Health Care Provider 50. MMWR Week:
diagnosed by: c Parent/Friend
51. MMWR Year:
c Other
44. Where was the patient born (country)? PREGnAnt woMEn
45. Is this case epi-linked to another c Y c N c U 52. If the case is female, is/was cY c N c U
confirmed or probable case? she pregnant during this
If “yes,” c Confirmed Varicella Case varicella illness?
epi-linked to: c Probable Varicella Case If “yes”:
c Herpes Zoster Case Number of weeks gestation at
onset of illness (1-45 weeks): Weeks
46. Transmission c Athletics c Hospital Outpatient
Setting c College Clinic Trimester c 1st Trimester
(Setting of at Onset
Exposure) c Community c Hospital Ward c 2nd Trimester
of Illness c 3rd Trimester
c Correctional Facility c International Travel
c Daycare c Military 53. General Comments:
c Doctor’s Office c Place of Worship
c Home c School
c Hospital ER c Work
c Other c Unknown