Form F-44236 - Pertussis Case Report - 2004 Page 2
ADVERTISEMENT
1
2
3
4DPH 4236 (Rev. 05/04)
Page 2 of 4
Name of case ________________________________
Complete Only for Children Ages <15 Years
Vaccinated with DTP or DTaP Vaccine?
Yes
No
Unknown
Vaccination Date
Type
Vaccine Type Codes
Manufacturer
Manufacturer Codes
Note: Record
1.
_____________
1. _____
W = DTP Whole Cell
1. _________
C = Connaught (Aventis)
type and
2.
______________
2. _____
A = DTaP
2. _________
L = Lederle (N/A)
manufacturer
3.
______________
3. _____
D = DT or Td
3. _________
S = SmithKline, Glaxo
codes for
4.
______________
4. _____
T = DTaP/Hib
4. _________
N = North American
children 2
5.
______________
5. _____
P = Pertussis only
5. _________
M = Massachusetts HD
months
6.
______________
6. _____
O = Other
6. _________
I = Michigan HD
through 6
U = Unknown
O = Other
years of age.
U = Unknown
Reason not vaccinated
with > 3 doses of
1. Religious exemption
4. Previous pertussis confirmed
7. Other
pertussis vaccine:
2. Medical contraindication
5. Parental refusal
9. Unknown
3. Philosophical exemption
6. Age <7 months
Were antibiotics given?
Yes
No
Unknown
First antibiotic received:
Check (ü) One
1. Erythromycin ( includes Pediazole, ilosone) recommended
Date started: _____________________
2. Trimethoprin-Sufamethoxazole ((bactrim/septra, TMP-SMZ) recommended
3. Clarithromycin/azithromycin recommended
Number of days taken: _____________
4. Tetracycline/Doxycycline
5. Amoxicillin/Penicillin/Ampicillin/Augmentin/Ceclor/Cefixime
6. Other ____________________________
9. Unknown
Second antibiotic received:
Check (ü) One
1. Erythromycin ( includes Pediazole, ilosone) recommended
Date started: _____________________
2. Trimethoprin-Sufamethoxazole (bactrim/septra, TMP-SMZ)) recommended
3. Clarithromycin/azithromycin recommended
Number of days taken: _____________
4. Tetracycline/Doxycycline
5. Amoxicillin/Penicillin/Ampicillin/Augmentin/Ceclor/Cefixime
6. Other ____________________________
9. Unknown
Possible SOURCE for this Case (for LHD use)
Telephone
Name of School, Daycare,
Cough
Name
Age
Address
Number
Employer
Onset Date
What is the Source Setting(s) of this Case?
1 Daycare
6 Hospital Outpatient Clinic
11 Military
2 School Work
7 Home
12 Correctional Facility
3 Doctor’s Office
8 Work
13 Church
4 Hospital Ward
9 Unknown
14 International Travel
5 Hospital ER
10 College
15 Other
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal