Varicella Case Report Form - Connecticut

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Connecticut Department of Public Health
Immunization Program
Varicella Case Report Form
(revised March 24, 2016)
Person reporting: _______________________________________________________________ Phone: (_______)________-________
Reporting site/clinic: __________________________________________________________
City: ____________________________
Date reported: ______/______/_________
Reporting site type:
School
Day care
Physician
Health department
Patient’s healthcare provider (if not the person reporting): _______________________________ Phone: (_______)________-________
Demographic information
Patient name: ______________________________________________________
DOB: ______/______/_________ Age: __________
Street address: ________________________________________ City: _______________________________ Zip: ________________
Parent/Guardian name (optional): __________________________________________________ Phone: (_______)________-________
Sex:
Male
Female
Other
Country of birth:
USA
Other __________
Unknown
Ethnicity:
Hispanic
Non-Hispanic
Unknown
Race:
White
Black
Asian
Hawaiian/Pacific Islander
American Indian/Alaska Native
Unknown
Other (specify) _________________________________
Attends:
School
Day care
Work
College
Other ______________________________
Name of institution: ______________________________________________
City: _________________________________
Clinical data
Rash onset: ______/______/_________
Fever?
Yes, temperature ________°F
Fever onset: ______/______/_________
No
Unknown
Number of lesions:
<50
50-249
250-499
>500
Rash description:
Generalized
Local
Unknown
Did the rash crust?
Yes, rash lasted ______ days before all crusted
No, rash lasted _______ days
Unknown
Diagnosed by:
Physician/nurse
Parent/guardian
School
Self
Other_____________
Laboratory tests
Medical history
Date
Positive
Negative
Not done
Is the patient pregnant?
Yes, due date: ______/______/_________
No
Unknown
DFA
PCR
Has the patient been diagnosed with varicella in the past?
Culture
Yes
No
Unknown
IgM
IgG
Varicella vaccine dates:
Other (specify)
#1 ______/______/_________
#2 ______/______/_________
____________
For patients born after the year 2000, is the patient up to date with varicella-containing vaccine (at least one dose by 16 months, at least 2
doses by 7 years)?
Yes
Unknown
No, reason:
MD diagnosis of previous disease at age ________ or date (if known) _____/_____/_______
Lab evidence of previous disease
Born outside the U.S.
Medical contraindication
Never offered vaccine
Parent/patient refusal
Parent/patient forgot to vaccinate
Religious exemption
Too young to vaccinate
Parent/patient report of previous disease
Other _______________________________________________
Unknown

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