Form PM358 "Rubella (German Measles) Case Report" - California

What Is Form PM358?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2010;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form PM358 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form PM358 "Rubella (German Measles) Case Report" - California

842 times
Rate (4.7 / 5) 51 votes
Mail to:
California Department of Public Health
Immunization Branch
850 Marina Bay Parkway
nd
Building P, 2
Floor, MS 7313
Richmond, CA 94804-6403
Or Fax to: (510) 620-3949
RUBELLA (GERMAN MEASLES) CASE REPORT
PATIENT DEMOGRAPHICS
Patient name—last
first
middle initial
Date of birth
Age (enter age and check one)
Gender
___/__/___
____
Days
Weeks
Months
Male
Female
Y
Address—number, street
City
State
ZIP code
County
Telephone number
Email:
(
)
(
)
Home
Work
ETHNICITY (check one)
RACE (check all that apply)
Hispanic/Latino
Black/African-American
Asian: Please specify:
Pacific Islander: Please specify:
Non-Hispanic/ Non-Latino
Native American/Alaskan Native
Asian Indian
Hmong
Thai
Native Hawaiian
Unknown
White
Cambodian
Japanese
Vietnamese
Guamanian
Unknown
Chinese
Korean
Other Asian:
Samoan
Other: _________________
Filipino
Laotian
_________________
Other Pacific Islander:
__________________
Country of birth
Country of residence
COMMON LHD TRACKING DATA
CMRID Number
IZB Case ID Number
WebCMR ID Number
Date reported to county
Date investigation started
Person/clinician reporting case
Reporter telephone
/
/_____
/
/_____
(
)
Case investigator completing form
Investigator telephone
Investigator’s jurisdiction
(
)
SIGNS AND SYMPTOMS
Rash
Rash onset date
Rash duration
Generalized rash
Origin on body
Direction of spread
/
/_____
Yes
No
Unknown
________
Yes
No
Unknown
days
Fever
Was temperature taken
Was temperature >99.0F (37.2C)
If temperature not taken, skin was
Fever onset date
/
/_____
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Hot
Warm
Normal
Unknown
Arthralgia/arthritis
Lymphadenopathy
Conjunctivitis
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Other symptoms
Describe other symptoms
Diagnosis date
/
/_____
Yes
No
Unknown
Does case meet clinical criteria for further investigation
CASE MEETS CDC/CSTE CLINICAL CRITERIA? (FOR STATE USE ONLY)
Yes
No
Unknown
Yes
No
Unknown
COMPLICATIONS AND OTHER SYMPTOMS
Hospitalized
If yes, number of days
Encephalitis
Death
If yes, date of death
hospitalized
/
/_____
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Other complications
Describe other complications
Yes
No
Unknown
LABORATORY TESTS
Lab tests done for rubella
CASE LAB CONFIRMED (FOR LHD USE)
CASE LAB CONFIRMED (FOR STATE USE ONLY)
LAB RESULT CODES
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
P = Positive
Serology performed
N = Negative – Antibody not detected
I = Indeterminate
Yes
No
Unknown
Specimen date
Result interpretation
E = Pending
IgM
P
N
I
E
X
U
/
/______
X = Not Done
IgG (acute)
P
N
I
E
X
U
/
/______
U = Unknown
IgG (convalescent)
P
N
I
E
X
U
/
/______
Specimen taken for virus isolation
Specimen Source
Specimen date
Virus isolated
Name of Lab:
/
/___
Yes
No
Unknown
Nasopharyngeal
Urine
Other
Unknown
Yes
No
Unknown
Specimen sent to CDC for genotyping
Date sent
Virus Genotype
Yes
No
Unknown
/__ /____
Other lab tests performed
Other lab test specimen
Specify other lab tests
Other lab test results
date
Yes
No
Unknown
/ __ /____
Page 1 of 2
PM 358 (8/10)
Mail to:
California Department of Public Health
Immunization Branch
850 Marina Bay Parkway
nd
Building P, 2
Floor, MS 7313
Richmond, CA 94804-6403
Or Fax to: (510) 620-3949
RUBELLA (GERMAN MEASLES) CASE REPORT
PATIENT DEMOGRAPHICS
Patient name—last
first
middle initial
Date of birth
Age (enter age and check one)
Gender
___/__/___
____
Days
Weeks
Months
Male
Female
Y
Address—number, street
City
State
ZIP code
County
Telephone number
Email:
(
)
(
)
Home
Work
ETHNICITY (check one)
RACE (check all that apply)
Hispanic/Latino
Black/African-American
Asian: Please specify:
Pacific Islander: Please specify:
Non-Hispanic/ Non-Latino
Native American/Alaskan Native
Asian Indian
Hmong
Thai
Native Hawaiian
Unknown
White
Cambodian
Japanese
Vietnamese
Guamanian
Unknown
Chinese
Korean
Other Asian:
Samoan
Other: _________________
Filipino
Laotian
_________________
Other Pacific Islander:
__________________
Country of birth
Country of residence
COMMON LHD TRACKING DATA
CMRID Number
IZB Case ID Number
WebCMR ID Number
Date reported to county
Date investigation started
Person/clinician reporting case
Reporter telephone
/
/_____
/
/_____
(
)
Case investigator completing form
Investigator telephone
Investigator’s jurisdiction
(
)
SIGNS AND SYMPTOMS
Rash
Rash onset date
Rash duration
Generalized rash
Origin on body
Direction of spread
/
/_____
Yes
No
Unknown
________
Yes
No
Unknown
days
Fever
Was temperature taken
Was temperature >99.0F (37.2C)
If temperature not taken, skin was
Fever onset date
/
/_____
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Hot
Warm
Normal
Unknown
Arthralgia/arthritis
Lymphadenopathy
Conjunctivitis
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Other symptoms
Describe other symptoms
Diagnosis date
/
/_____
Yes
No
Unknown
Does case meet clinical criteria for further investigation
CASE MEETS CDC/CSTE CLINICAL CRITERIA? (FOR STATE USE ONLY)
Yes
No
Unknown
Yes
No
Unknown
COMPLICATIONS AND OTHER SYMPTOMS
Hospitalized
If yes, number of days
Encephalitis
Death
If yes, date of death
hospitalized
/
/_____
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Other complications
Describe other complications
Yes
No
Unknown
LABORATORY TESTS
Lab tests done for rubella
CASE LAB CONFIRMED (FOR LHD USE)
CASE LAB CONFIRMED (FOR STATE USE ONLY)
LAB RESULT CODES
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
P = Positive
Serology performed
N = Negative – Antibody not detected
I = Indeterminate
Yes
No
Unknown
Specimen date
Result interpretation
E = Pending
IgM
P
N
I
E
X
U
/
/______
X = Not Done
IgG (acute)
P
N
I
E
X
U
/
/______
U = Unknown
IgG (convalescent)
P
N
I
E
X
U
/
/______
Specimen taken for virus isolation
Specimen Source
Specimen date
Virus isolated
Name of Lab:
/
/___
Yes
No
Unknown
Nasopharyngeal
Urine
Other
Unknown
Yes
No
Unknown
Specimen sent to CDC for genotyping
Date sent
Virus Genotype
Yes
No
Unknown
/__ /____
Other lab tests performed
Other lab test specimen
Specify other lab tests
Other lab test results
date
Yes
No
Unknown
/ __ /____
Page 1 of 2
PM 358 (8/10)
Rubella (German Measles) Case Report—PM 358
VACCINATION/MEDICAL HISTORY
Received one or more doses of rubella containing vaccine
If yes, number of doses
Yes
No
Unknown
Dates of vaccination–Dose 1
Dose 2
Dose 3
/
/______
/
/______
/
/______
Reason not vaccinated (check all that apply)
1
Personal Beliefs Exemption (PBE)
4
Lab confirmation of previous disease
7
Delay in starting series or between doses
2
Permanent Medical Exemption (PME)
5
MD diagnosis of previous disease
8
Other
3
Temporary Medical Exemption
6
Under age for vaccination
9
Unknown
Prior MD diagnosed rubella (see reason 5)
Pregnant
Immunocompromised
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
EPIDEMIOLOGICAL EXPOSURE HISTORY
Setting (check all that apply)
1
Day care
4
Hospital Ward
7
Home
10
College
13
Church
2
School
5
Hospital ER
8
Work
11
Military
14
International travel
3
Doctor’s office
6
Outpatient hospital clinic
9
Unknown
12
Correctional facility
15
Other
Recent travel or arrival from other country or state within 23 days of rash onset?
Yes
No
Unknown
Date of arrival in California
Countries or states visited
Dates in countries or states visited
/
/______
Close contact with person(s) with rash or person(s) with congenital rubella syndrome (CRS) 12-23 days before rash onset?
Yes
No
Unknown
Name
Rash Onset Date
Relationship
Age (Years)
Same Household
1
Yes
No
Unknown
/
/______
Yes
No
Unknown
2
/
/______
Yes
No
Unknown
3
/
/______
Please list other contacts on a separate sheet or use the contact tracing work sheet.
Epi-linked to a lab-confirmed case?
Case Name or Case ID
Outbreak related
Outbreak Name or Location
Yes
No
Unknown
Yes
No
Unknown
Import status
If case is indigenous, is case
If case is imported, describe source
Indigenous
Out-of-state import
Import-linked (linked to imported case)
Endemic
Unknown Source
International Import
Imported virus (viral genetic evidence indicates an imported genotype)
CONTACT INVESTIGATION
Setting (check all that apply)
1
Day care
4
Hospital Ward
7
Home
10
College
13
Church
2
School
5
Hospital ER
8
Work
11
Military
14
International travel
3
Doctor’s office
6
Outpatient hospital clinic
9
Unknown
12
Correctional facility
15
Other
Number of susceptible contacts
Number of susceptible contacts who are pregnant
Close contacts who have rash 12-23 days after exposure to case (list below)
Yes
No
Unknown
Name
Rash Onset Date
Relationship
Age (Years)
Same Household
Yes
No
Unknown
1
/
/______
Yes
No
Unknown
2
/
/______
Yes
No
Unknown
3
/
/______
Please list other contacts on a separate sheet or use the contact tracing work sheet.
CASE CLASSIFICATION (FOR LHD USE)
CASE CLASSIFICATION (FOR STATE USE ONLY)
Confirmed
Probable
Suspect
Not a case
Unknown
Confirmed
Probable
Suspect
Not a case
Unknown
RUBELLA (German measles) 2010 CASE DEFINITION CSTE Position Statement Number: 09-ID-55
Case classification
Suspected: Any generalized rash illness of acute onset that does not meet the criteria for probable or confirmed rubella or any other illness
Probable: In the absence of a more likely diagnosis, an illness characterized by all of the following: acute onset of generalized maculopapular rash; AND
temperature greater than 99.0° F or 37.2° C, if measured; AND arthralgia, arthritis, lymphadenopathy, or conjunctivitis AND lack of epidemiologic linkage to a
laboratory-confirmed case of rubella; AND noncontributory or no serologic or virologic testing.
Confirmed: A case with or without symptoms who has laboratory evidence of rubella infection confirmed by one or more of the following laboratory tests:
isolation of rubella virus; OR detection of rubella-virus specific nucleic acid by polymerase chain reaction; OR significant rise between acute- and convalescent-
phase titers in serum rubella immunoglobulin G antibody level by any standard serologic assay; OR positive serologic test for rubella immunoglobulin M (IgM)
antibody;
OR
An illness characterized by all of the following: acute onset of generalized maculopapular rash; AND temperature greater than 99.0°F or 37.2°C; AND arthralgia,
arthritis, lymphadenopathy, or conjunctivitis; AND epidemiologic linkage to a laboratory-confirmed case of rubella.
Page 2 of 2
PM 358 (8/10)
Page of 2