"Varicella Case Report Form" - Connecticut

Varicella Case Report Form is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

Form Details:

  • Released on August 3, 2018;
  • The latest edition currently provided by the Connecticut State Department of Public Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

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Download "Varicella Case Report Form" - Connecticut

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Connecticut Department of Public Health
Immunization Program
Varicella Case Report Form
(revised August 3, 2018)
Person reporting: _______________________________________________________________ Phone: (_______)________-________
Reporting site/clinic: __________________________________________________________
City: ____________________________
Date reported: ______/______/_________
Reporting site type:
School
Day care
Physician
Health department
Patient’s healthcare provider (if not the person reporting): _______________________________ Phone: (_______)________-________
Demographic information
Patient name: ______________________________________________________
DOB: ______/______/_________ Age: __________
Street address: ________________________________________ City: _______________________________ Zip: ________________
Parent/Guardian name (optional): __________________________________________________ Phone: (_______)________-________
Sex:
Male
Female
Other
Country of birth:
USA
Other __________
Unknown
Ethnicity:
Hispanic
Non-Hispanic
Unknown
Race:
White
Black
Asian
Hawaiian/Pacific Islander
American Indian/Alaska Native
Unknown
Other (specify) _________________________________
Attends:
School
Day care
Work
College
Other ______________________________
Name of institution: ______________________________________________
City: _________________________________
Clinical data
Rash onset: ______/______/_________
Fever?
Yes, temperature ________°F
Fever onset: ______/______/_________
No
Unknown
Number of lesions:
<50
50-249
250-499
>500
Rash description:
Generalized
Local
Unknown
Did the rash crust?
Yes, rash lasted ______ days before all crusted
No, rash lasted _______ days
Unknown
Diagnosed by:
Physician/nurse
Parent/guardian
School
Self
Other_____________
Laboratory tests
Medical history
Date
Positive
Negative
Not done
Is the patient pregnant?
Yes, due date: ______/______/_________
No
Unknown
DFA
PCR
Has the patient been diagnosed with varicella in the past?
Culture
Yes
No
Unknown
IgM
IgG
Varicella vaccine dates:
Other (specify)
#1 ______/______/_________
#2 ______/______/_________
____________
For patients born after the year 2000, is the patient up to date with varicella-containing vaccine (at least one dose by 16 months, at least 2
doses by 7 years)?
Yes
Unknown
No, reason:
MD diagnosis of previous disease at age ________ or date (if known) _____/_____/_______
Lab evidence of previous disease
Born outside the U.S.
Medical contraindication
Never offered vaccine
Parent/patient refusal
Parent/patient forgot to vaccinate
Religious exemption
Too young to vaccinate
Parent/patient report of previous disease
Other _______________________________________________
Unknown
Connecticut Department of Public Health
Immunization Program
Varicella Case Report Form
(revised August 3, 2018)
Person reporting: _______________________________________________________________ Phone: (_______)________-________
Reporting site/clinic: __________________________________________________________
City: ____________________________
Date reported: ______/______/_________
Reporting site type:
School
Day care
Physician
Health department
Patient’s healthcare provider (if not the person reporting): _______________________________ Phone: (_______)________-________
Demographic information
Patient name: ______________________________________________________
DOB: ______/______/_________ Age: __________
Street address: ________________________________________ City: _______________________________ Zip: ________________
Parent/Guardian name (optional): __________________________________________________ Phone: (_______)________-________
Sex:
Male
Female
Other
Country of birth:
USA
Other __________
Unknown
Ethnicity:
Hispanic
Non-Hispanic
Unknown
Race:
White
Black
Asian
Hawaiian/Pacific Islander
American Indian/Alaska Native
Unknown
Other (specify) _________________________________
Attends:
School
Day care
Work
College
Other ______________________________
Name of institution: ______________________________________________
City: _________________________________
Clinical data
Rash onset: ______/______/_________
Fever?
Yes, temperature ________°F
Fever onset: ______/______/_________
No
Unknown
Number of lesions:
<50
50-249
250-499
>500
Rash description:
Generalized
Local
Unknown
Did the rash crust?
Yes, rash lasted ______ days before all crusted
No, rash lasted _______ days
Unknown
Diagnosed by:
Physician/nurse
Parent/guardian
School
Self
Other_____________
Laboratory tests
Medical history
Date
Positive
Negative
Not done
Is the patient pregnant?
Yes, due date: ______/______/_________
No
Unknown
DFA
PCR
Has the patient been diagnosed with varicella in the past?
Culture
Yes
No
Unknown
IgM
IgG
Varicella vaccine dates:
Other (specify)
#1 ______/______/_________
#2 ______/______/_________
____________
For patients born after the year 2000, is the patient up to date with varicella-containing vaccine (at least one dose by 16 months, at least 2
doses by 7 years)?
Yes
Unknown
No, reason:
MD diagnosis of previous disease at age ________ or date (if known) _____/_____/_______
Lab evidence of previous disease
Born outside the U.S.
Medical contraindication
Never offered vaccine
Parent/patient refusal
Parent/patient forgot to vaccinate
Religious exemption
Too young to vaccinate
Parent/patient report of previous disease
Other _______________________________________________
Unknown
Did the patient develop any complications that were diagnosed by a healthcare provider? [Check all that apply]
Yes
No
Unknown
Skin/soft tissue infection
Cerebellitis/ataxia
Encephalitis
Dehydration/hypovolemia
Hemorrhagic condition
Pneumonia (diagnosed by
X-ray
MD
unknown)
Meningitis
Other complications (Specify: ____________________________)
Was the patient treated with antivirals?
Yes, name: ___________________________ Started on ______/______/_________
No or N/A
Unknown
Is the patient immunocompromised due to a medical condition or treatment?
Yes, specify ____________________________________________________________
No
Unknown
Does the patient have any co-morbid medical conditions?
Yes, specify
________________________
No
Unknown
Did the patient die from varicella or complications (including secondary infection) associated with varicella?
No
Unknown
Yes, date of death: ______/______/_________
Autopsy performed?
Yes
No
Unknown
Cause of death: _____________________________________________________
Was the patient hospitalized?
No
Unknown
Yes, name of hospital _____________________________________________________
Admit date: ______/______/_________ Discharge date: ______/______/_________
Primary reason for hospitalization (Specify chief complaint and/or admission
________________________________________________
diagnosis):
_______________________________________________________
Severe varicella presentation
Unknown
Varicella-related complication
Observation
Administration of IV treatment
Isolation
Non-varicella hospitalization with coincident varicella
Other _________________________________________________
Return form to: Connecticut Department of Public Health
Immunization Program
410 Capitol Ave, MS #11MUN
Hartford, CT 06134
or fax form to (860) 707-1905
Questions? Call (860) 509-7929
DPH use only
CTEDSS ID: ___________________
Case status:
Confirmed
Probable
Suspect
Not a case
Epi-linked to another case?
Yes, case ID ___________________
No
Unknown
Outbreak linked?
Yes, name of outbreak: ______________________________________
No
Unknown
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