Form CS106190 Appendix 18 "Tetanus Surveillance Worksheet"

What Is Form CS106190 Appendix 18?

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Download Form CS106190 Appendix 18 "Tetanus Surveillance Worksheet"

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Tetanus Surveillance Worksheet
Appendix 18
NAME (Last, First)
Hospital Record No.
Address (Street and No.)
City
County
Zip
Phone
Reporting Physician/Nurse/Hospital/Clinic/Lab Phone
Address
Phone
DETACH HERE and transmit only lower portion if sent to CDC
CDC NETSS ID
County
State
Zip
Birth Date
Age
Age Type
Race
Ethnicity
Sex
0 = 0-120 years
3 = 0-28 days
N = Native Amer./Alaska Native W = White
H = Hispanic
M = Male
1 = 0-11 months
9 = Unknown
A = Asian/Pacific Islander
O = Other
N = Not Hispanic
F = Female
2 = 0-52 weeks
B = African American
U = Unknown
U = Unknown
Unknown= 999
U = Unknown
Month
Day
Year
Event Date
Event Type
Reported
Imported
Report Status
1 = Onset Date
5 = Reported to State or
1 = Indigenous
1 = Confirmed
2 = Diagnosis Date
MMWR Report Date
2 = International
2 = Probable
3 = Lab Test Done
6 = Unknown
3 = Out of State
3 = Suspect
4 = Reported to County
9 = Unknown
9 = Unknown
Month
Day
Year
Month
Day
Year
Date
Year of Onset
Acute Wound
Date Wound Occurred
Principal Anatomic Site
Identified?
1 = Head
2 = Trunk
Y = Yes
3 = Upper Extremity
Month
Day
Year
Month
Day
Year
N = No
4 = Lower Extremity
U = Unknown
9 = Unspecified
Occupation
Work Related?
Environment
Circumstances
Y = Yes
0 = Home
3 = Automobile
History of Military Service
Year of Entry into
N = No
1 = Other Indoors
4 = Other Outdoors
U = Unknown
(Active or Reserve)?
Military Service
2 = Farm / Yard
9 = Unknown
Principal Wound Type
Wound
Y = Yes
Contaminated?
N = No
1 = Puncture
7 = Burn
12 = Animal Bite
U = Unknown
2 = Stellate Laceration
8 = Frostbite
13 = Insect Bite/Sting
3 = Linear Laceration
9 = Compound Fracture
14 = Dental
Y = Yes
4 = Crush
10 = Other (e.g. with cancer)
15 = Tissue Necrosis
N = No
Specify
: ____________
99 = Unknown
5 = Abrasion
U = Unknown
Tetanus Toxoid Vaccination
Years Since
6 = Avulsion
11 = Surgery
History Prior to Tetanus Disease
Last Dose
Depth of Wound
Signs of Infection?
Devitalized, Ischemic, or
(Exclude Doses Received Since Acute Injury)
Denervated Tissue Present?
0 = Never
3 = 3 doses
1 = 1 cm. or less
Y = Yes
Y = Yes
0 - 98
1 = 1 dose
4 = 4+ doses
2 = more than 1 cm.
N = No
N = No
99 = Unknown
2 = 2 doses
9 = Unknown
9 = Unknown
U = Unknown
U = Unknown
Was Medical Care Obtained
Tetanus Toxoid (TT/Td/Tdap)
If Yes, How Soon After Injury?
For This Acute Injury
Administered Before Tetanus Onset
1 = < 6 Hours
5 = 10 - 14 Days
Y = Yes
Y = Yes
2 = 7 - 23 Hours
6 = 15+ Days
N = No
N = No
3 = 1 - 4 Days
9 = Unknown
U = Unknown
U = Unknown
4 = 5 - 9 Days
Wound Debrided Before
If Yes, Debrided How Soon
Tetanus Immune Globulin
If Yes, TIG Given How Soon
Dosage
(Units)
Tetanus Onset
After Injury
(TIG) Prophylaxis Received
After Injury?
Before Tetanus Onset
1 = < 6 Hours
5 = 10 - 14 Days
1 = < 6 Hours
5 = 10 - 14 Days
Y = Yes
Y = Yes
2 = 7 - 23 Hours
6 = 15+ Days
2 = 7 - 23 Hours
6 = 15+ Days
0 - 998
N = No
N = No
3 = 1 - 4 Days
9 = Unknown
3 = 1 - 4 Days
9 = Unknown
999 = Unknown
U = Unknown
U = Unknown
4 = 5 - 9 Days
4 = 5 - 9 Days
Associated Condition
Describe Condition:
Diabetes?
If Yes, Insulin-
Parenteral Drug
Describe Condition:
(If no Acute Injury)
Dependent?
Abuse?
Y = Yes
Y = Yes
Y = Yes
1 = Abscess
6 = Other Infection
2 = Ulcer
7 = Cancer
N = No
N = No
N = No
U = Unknown
U = Unknown
U = Unknown
3 = Blister
8 = Gingivitis
4 = Gangrene
88 = None
5 = Cellulitis
99 = Unknown
Type of Tetanus Disease
TIG Therapy Given
If Yes, How Soon After Illness Onset?
Dosage
(Units)
After Tetanus Onset
1 = Generalized
Y = Yes
1 = < 6 Hours
5 = 10 - 14 Days
0 - 998
2 = 7 - 23 Hours
6 = 15+ Days
2 = Localized
N = No
999 = Unknown
3 = Cephalic
U = Unknown
3 = 1 - 4 Days
9 = Unknown
4 = Unknown
4 = 5 - 9 Days
Days Hospitalized
Days In ICU
Days Received Mechanical Ventilation
0 - 998
0 - 998
0 - 998
999 = Unknown
999 = Unknown
999 = Unknown
Outcome One Month After Onset?
If Died, Date of Death
R = Recovered
C = Convalescing
D = Died
Month
Day
Year
Page 1 of 2
Tetanus Surveillance Worksheet
Appendix 18
NAME (Last, First)
Hospital Record No.
Address (Street and No.)
City
County
Zip
Phone
Reporting Physician/Nurse/Hospital/Clinic/Lab Phone
Address
Phone
DETACH HERE and transmit only lower portion if sent to CDC
CDC NETSS ID
County
State
Zip
Birth Date
Age
Age Type
Race
Ethnicity
Sex
0 = 0-120 years
3 = 0-28 days
N = Native Amer./Alaska Native W = White
H = Hispanic
M = Male
1 = 0-11 months
9 = Unknown
A = Asian/Pacific Islander
O = Other
N = Not Hispanic
F = Female
2 = 0-52 weeks
B = African American
U = Unknown
U = Unknown
Unknown= 999
U = Unknown
Month
Day
Year
Event Date
Event Type
Reported
Imported
Report Status
1 = Onset Date
5 = Reported to State or
1 = Indigenous
1 = Confirmed
2 = Diagnosis Date
MMWR Report Date
2 = International
2 = Probable
3 = Lab Test Done
6 = Unknown
3 = Out of State
3 = Suspect
4 = Reported to County
9 = Unknown
9 = Unknown
Month
Day
Year
Month
Day
Year
Date
Year of Onset
Acute Wound
Date Wound Occurred
Principal Anatomic Site
Identified?
1 = Head
2 = Trunk
Y = Yes
3 = Upper Extremity
Month
Day
Year
Month
Day
Year
N = No
4 = Lower Extremity
U = Unknown
9 = Unspecified
Occupation
Work Related?
Environment
Circumstances
Y = Yes
0 = Home
3 = Automobile
History of Military Service
Year of Entry into
N = No
1 = Other Indoors
4 = Other Outdoors
U = Unknown
(Active or Reserve)?
Military Service
2 = Farm / Yard
9 = Unknown
Principal Wound Type
Wound
Y = Yes
Contaminated?
N = No
1 = Puncture
7 = Burn
12 = Animal Bite
U = Unknown
2 = Stellate Laceration
8 = Frostbite
13 = Insect Bite/Sting
3 = Linear Laceration
9 = Compound Fracture
14 = Dental
Y = Yes
4 = Crush
10 = Other (e.g. with cancer)
15 = Tissue Necrosis
N = No
Specify
: ____________
99 = Unknown
5 = Abrasion
U = Unknown
Tetanus Toxoid Vaccination
Years Since
6 = Avulsion
11 = Surgery
History Prior to Tetanus Disease
Last Dose
Depth of Wound
Signs of Infection?
Devitalized, Ischemic, or
(Exclude Doses Received Since Acute Injury)
Denervated Tissue Present?
0 = Never
3 = 3 doses
1 = 1 cm. or less
Y = Yes
Y = Yes
0 - 98
1 = 1 dose
4 = 4+ doses
2 = more than 1 cm.
N = No
N = No
99 = Unknown
2 = 2 doses
9 = Unknown
9 = Unknown
U = Unknown
U = Unknown
Was Medical Care Obtained
Tetanus Toxoid (TT/Td/Tdap)
If Yes, How Soon After Injury?
For This Acute Injury
Administered Before Tetanus Onset
1 = < 6 Hours
5 = 10 - 14 Days
Y = Yes
Y = Yes
2 = 7 - 23 Hours
6 = 15+ Days
N = No
N = No
3 = 1 - 4 Days
9 = Unknown
U = Unknown
U = Unknown
4 = 5 - 9 Days
Wound Debrided Before
If Yes, Debrided How Soon
Tetanus Immune Globulin
If Yes, TIG Given How Soon
Dosage
(Units)
Tetanus Onset
After Injury
(TIG) Prophylaxis Received
After Injury?
Before Tetanus Onset
1 = < 6 Hours
5 = 10 - 14 Days
1 = < 6 Hours
5 = 10 - 14 Days
Y = Yes
Y = Yes
2 = 7 - 23 Hours
6 = 15+ Days
2 = 7 - 23 Hours
6 = 15+ Days
0 - 998
N = No
N = No
3 = 1 - 4 Days
9 = Unknown
3 = 1 - 4 Days
9 = Unknown
999 = Unknown
U = Unknown
U = Unknown
4 = 5 - 9 Days
4 = 5 - 9 Days
Associated Condition
Describe Condition:
Diabetes?
If Yes, Insulin-
Parenteral Drug
Describe Condition:
(If no Acute Injury)
Dependent?
Abuse?
Y = Yes
Y = Yes
Y = Yes
1 = Abscess
6 = Other Infection
2 = Ulcer
7 = Cancer
N = No
N = No
N = No
U = Unknown
U = Unknown
U = Unknown
3 = Blister
8 = Gingivitis
4 = Gangrene
88 = None
5 = Cellulitis
99 = Unknown
Type of Tetanus Disease
TIG Therapy Given
If Yes, How Soon After Illness Onset?
Dosage
(Units)
After Tetanus Onset
1 = Generalized
Y = Yes
1 = < 6 Hours
5 = 10 - 14 Days
0 - 998
2 = 7 - 23 Hours
6 = 15+ Days
2 = Localized
N = No
999 = Unknown
3 = Cephalic
U = Unknown
3 = 1 - 4 Days
9 = Unknown
4 = Unknown
4 = 5 - 9 Days
Days Hospitalized
Days In ICU
Days Received Mechanical Ventilation
0 - 998
0 - 998
0 - 998
999 = Unknown
999 = Unknown
999 = Unknown
Outcome One Month After Onset?
If Died, Date of Death
R = Recovered
C = Convalescing
D = Died
Month
Day
Year
Page 1 of 2
Tetanus Surveillance Worksheet
NAME (Last, First)
Hospital Record No.
Address (Street and No.)
City
County
Zip
Phone
Reporting Physician/Nurse/Hospital/Clinic/Lab Phone
Address
Phone
DETACH HERE and transmit only lower portion if sent to CDC
Mother’s Age
Mother’s
Date Mother’s
Mother’s Tetanus Toxoid Vaccination
Years Since Mother’s
in Years
Birth Date
Arrival in U.S.
History PRIOR to Child’s Disease
Last Dose
(Known Doses Only)
0 = Never
3 = 3 doses
1 = 1 dose
4 = 4+ doses
2 = 2 doses
9 = Unknown
Month
Day
Year
Month
Day
Year
99 = Unknown
0 - 98
99 = Unknown
Child’s Birthplace
Birth Attendant(s)
Other Birth Attendant(s)
(If Not Previously Listed)
1 = Hospital
1 = Physician
4 = Unlicensed Midwife
2 = Home
2 = Nurse
5 = Other
3 = Other
3 = Licensed Midwife
9 = Unknown
9 = Unknown
Other Comments?
Reporter’s Name
Title
Y = Yes
N = No
U = Unknown
Institution Name
Phone Number
Date Reported
Month
Day
Year
Clinical Case Definition*:
Acute onset of hypertonia and/or painful muscular contractions (usually of the muscles of the jaw and neck) and generalized muscle spasms
Case Classification*:
Confirmed: A clinically compatible case, as reported by a health-care professional.
Notes/Other Information:
*CDC. Case Definitions for Infectious Conditions Under Public Health Surveillance. MMWR 1997;46(No. RR-10):39
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