Measles Case Report Form - Georgia Department Of Public Health Page 2
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2VACCINATION HISTORY
Vaccinated? (Received any doses of measles-containing vaccines)
No. doses of measles-containing vaccine received prior to
□
□
□
illness onset? ______
Yes
No
Unknown
Dose
Vaccination date
Vaccine type
Vaccine manufacturer
Lot number
____/____/____
Dose 1
____/____/____
Dose 2
Prior MD diagnosis of measles? □ Yes □ No □ Unknown
□
Reason patient not age-appropriately vaccinated
Unknown
□
□
□
Religious exemption
□ Lab confirma on of previous disease
Forgot
Other
□
□
□
Parental/Patient refusal □ Medical contraindica on
Inconvenience
Too young
□
□
□
Too expensive
Unaware
Philosophical exemption □ MD diagnosis of previous disease
EPIDEMIOLOGIC INFORMATION
Employed at or attends
□ Yes □ No □ Unknown
Is patient a healthcare
Date first reported to public health:___/___/____
school?
worker?
Epi-linked? □ Yes □ No □ Unknown
□ Yes □ No □ Unknown
□ Yes, w/ direct
Employed at or attends child
patient contact
care?
□ Yes, w/o direct
Name of Epi-linked case:
_____________
Is patient incarcerated?
□ Yes □ No □ Unknown
patient contact
Is patient instutionalized?
□ Yes □ No □ Unknown
SendSS ID of Epi-linked case: _______________
Outbreak related? □ Yes □ No □ Unknown
□ No
Is patient pregnant?
□ Yes □ No □ Unknown
Outbreak name or location:
Is patient
□ Unknown
□ Yes □ No □ Unknown
immunocompromised?
EXPOSURE HISTORY
Recent travel or arrival from other country or state within 18 days of rash onset? □Yes □No □Unknown
Type of travel: □Interna onal □Domes c
Visited tourist attraction? □Yes □No □Unknown
Date returned to Georgia
Countries or states visited:
Dates in countries or states visited
___/___/____ to ___/____/____
____/____/_____
___/___/____ to ___/____/____
Tourist attraction visited:
Close contact with person(s) with rash 8‐17 days before rash onset? □Yes □No □Unknown
Name
Rash onset date
Relationship
Same Household
Age(Years)
1
___/___/___
2
___/___/___
3
___/___/___
4
___/___/___
Setting of further documented spread from case
Transmission setting (Where did this case acquire pertussis?)
(outside of household) (use number codes from
□ Outpatient clinic (6)
□ Daycare (1)
□ Military (11)
transmission setting question above)
□ School (2)
□ Home (7)
□ Correc onal facility (12)
________ (no documented spread = 16)
□ Place of worship (13)
□ Doctor's Office (3) □ Work (8)
□ Hospital Ward (4) □ Unknown (9)
□ Interna onal travel (14)
□ Hospital ER (5)
□ College (10)
□ Other (15)
Import status: □ Indigenous □Out‐of‐state import □Interna onal Import
Number of
If case is indigenous, is case □Import‐linked (linked to imported case) □ Endemic
susceptible
□ Imported virus (viral gene c evidence indicates an imported genotype) □ Unknown Source
contacts ________
If case is imported, describe source
Comments:
Updated January 2015
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