Form F-44236 - Pertussis Case Report - 2004
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4DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
s.252.05, Wis. Stats.
F-44236 (Rev. 05/04)
(608) 266-2346
PERTUSSIS CASE REPORT
The information collected on this form is required by HFS 145 (02). The information will be used for reporting disease and for the purpose of
surveillance, prevention, and control of Pertussis disease. Read instructions and definitions on the last page before completing form.
___________________________
State Case ID
Name of Patient(Last, First)
Street Address
City
State
Zip
County
Name of Parent or Legal Guardian
Telephone Number
Birth Date(mm/dd/yyyy)
Gender
Race
Ethnicity
1 Male
1 Native American / Alaskan Native
5 White
1 Hispanic
Age
2 Female
2 Asian / Pacific Islander
8 Other
2 Non-Hispanic
9 Unknown
3 African American
9 Unknown
9 Unknown
Name of School/Day Care Center/Employer
Is this Case
Case status
1 Indigenous (acquired in Wisconsin)?
1 Confirmed
2 International (acquired outside the USA)?
2 Probable
3 Out of State (acquired in a state outside of Wis.)?
3 Suspected
9 Unknown?
9 Unknown
Reporting Physician / Laboratory / Hospital / Clinic / Local Health Department(LHD) / Other
Telephone Number
LHD
Date reported to
Date investigation
Investigated by
Date reported to
LHD
started
Immunization Program
Laboratory Testing
Date specimen collected
Result
Result Codes
Done
PCR
______________________
_____
P = Positive
N = Negative
Culture
______________________
_____
I = Indeterminate
Yes
DFA
______________________
_____
st
E = Pending
No
Serology (1
)
______________________
_____
nd
Unknown
Serology (2
)
______________________
_____
X = Not Done
S = Parapertussis
U = Unknown
Catarrhal
Catarrhal
Catarrhal phase
Paroxysmal
Paroxysmal
Whoop
Vomit
(cold-like)
phase cough
cough onset
cough
cough onset date
symptom
date
Yes
Yes
Yes
Yes
onset date
No
No
No
No
Unknown
Unknown
Unknown
Unknown
Apnea
Sleep
Cough persisting at
Duration of cough at final
Final interview date
disturbance
final interview
interview
Yes
Yes
Yes
______ Days
Unknown
No
No
No
Unknown
Unknown
Unknown
Chest X-ray for
Seizures
Acute encephalopathy
Hospitalized
Died
Pneumonia
Positive
Yes
Yes
Yes, _____ Number of Days
Yes
Negative
No
No
No
No
Not Done
Unknown
Unknown
Unknown
Unknown
Unknown
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