Form F-44236 - Pertussis Case Report - 2004 Page 3
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4DPH 4236 (Rev. 05/04)
Page 3 of 4
Name of case ________________________________
Possible SPREAD from this Case (for LHD use)
Household Members (list all siblings, adults, roommates etc.)
Name
Age
Relation
Name of school, day care center,
Total
Treatment Drug
Start
Total
to case
clubs, employer, church, baby sitter,
doses
Date
Days
etc.
of DTP
Taken
-DTaP
Close Contacts (list all face to face non-household)
Name
Age
Relation
Name of school, day care center,
Total
Treatment Drug
Start
Total
to case
clubs, employer, church, baby sitter,
doses
Date
Days
etc.
of DTP
Taken
-DTaP
Groups Notified
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