Form CDC52.5 "Typhoid and Paratyphoid Fever Surveillance Report"

What Is Form CDC52.5?

This is a legal form that was released by the U.S. Department of Health and Human Services - Centers for Disease Control and Prevention on March 1, 2007 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2007;
  • The latest available edition released by the U.S. Department of Health and Human Services - Centers for Disease Control and Prevention;
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DEPARTMENT OF
TYPHOID AND PARATYPHOID FEVER SURVEILLANCE REPORT
HEALTH & HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
STATE LAB ISOLATE ID NO.
ATLANTA, GA 30333
CDC NO.:
Instructions:
Form Approved:
– Please complete this form only for new, symptomatic, culture-proven cases of typhoid or paratyphoid fever. –
OMB No. 0920-0728
DEMOGRAPHIC DATA
1. Reporting
2. First three letters of
3. Date
or Age:
State:
patient’s last name:
of birth:
(in years)
Mo.
Day
Yr.
4. Sex:
5. Does the patient work as a foodhandler?
6. Citizenship:
Male
Female
Yes
No
Unk.
U.S.
Other:
Unk.
CLINICAL DATA
7. Was the patient ill with typhoid
8. Was the patient
If Yes, give date of
If Yes, how many days was
9. Outcome
or paratyphoid fever? (fever,
hospitalized?
onset of symptoms:
the patient hospitalized?
of case:
abdominal pain, headache, etc)
Recovered
Died
Yes
No
Unk.
Yes
No
Unk.
Unk.
Mo.
Day
Yr.
Days
LABORATORY DATA
10. Date Salmonella first isolated:
Site(s) of isolation:
(check all that apply)
Blood
Stool
Gall Bladder
Other (specify):
Mo.
Day
Yr.
Serotype:
Typhi
Paratyphi A
Paratyphi B
Paratyphi C
11. Was antibiotic sensitivity testing performed
{
• Ampicillin:
No
Not tested
Yes
on this (these) isolate(s) at the laboratory?
If Yes, was
Chlor
amphenicol:
(Please contact the clinical laboratory for
Not tested
Yes
No
the organism
this information)
• Trimethoprim-sulfamethoxazole:
Not tested
Yes
No
resistant to:
• Fluoroquinolones (e.g., Ciprofloxacin):
No
Not tested
Yes
Yes
No
Unk.
EPIDEMIOLOGIC DATA
12. Did this case occur as part of an outbreak?
(two or more cases of typhoid or paratyphoid fever associat
ed by time and place)
Yes
No
Unk.
{
Year received
13. Did the patient receive typhoid vaccination
(primary series or booster) within
• Oral Ty21a or Vivotif (Berna) four pill series:
If Yes,
Yes
No
Unk.
five years before onset of illness?
indicate type
of vaccine
Yes
No
Unk.
• ViCPS or Typhim Vi shot (Pasteur Merieux):
received:
No
Unk.
Yes
14. Did the patient travel or live outside
If Yes, please list in order the countries visited during the 30 days
Date of most recent return or
the United States during the 30 days
before the illness began: (other than the United States)
entry to the United States:
before the illness began?
1.
3.
Yes
No
Unk.
2.
4.
Mo.
Day
Yr.
15. Was the purpose of the international travel:
a. Business?
d. Immigration to U.S.?
Unk.
Unk.
Yes
No
Yes
No
b. Tourism?
e. Other?
No
Unk.
No
Unk.
Yes
Yes
c. Visiting relatives or friends?
Unk.
No
Yes
(if other, specify):
16. Was the case
If Yes, was the carrier previously
traced to a typhoid or paratyphoid carrier?
known to the health department?
Unk.
No
No
Unk.
Yes
Yes
17. Comments:
18. Name of Person
Completing Form:
Address:
Telephone:
Date:
Mo.
Day
Yr.
– THANK YOU VERY MUCH FOR TAKING THE TIME TO COMPLETE THIS FORM –
Please send a copy to your STATE EPIDEMIOLOGY OFFICE and the
Enteric Diseases Epidemiology Branch, Centers for Disease Control and Prevention
Mailstop C-09, Atlanta, Georgia 30333 • Fax: (404) 639-2205
Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0728).
TYPHOID AND PARATYPHOID FEVER SURVEILLANCE REPORT
CDC 52.5 (E), June 1997, Revised March 2007
PAGE 1 OF 1
CS246979
(CDC Adobe Acrobat 10.1, S508 Electronic Version, November 2012)
Print
Save Form
Reset Form
DEPARTMENT OF
TYPHOID AND PARATYPHOID FEVER SURVEILLANCE REPORT
HEALTH & HUMAN SERVICES
CENTERS FOR DISEASE CONTROL
AND PREVENTION
STATE LAB ISOLATE ID NO.
ATLANTA, GA 30333
CDC NO.:
Instructions:
Form Approved:
– Please complete this form only for new, symptomatic, culture-proven cases of typhoid or paratyphoid fever. –
OMB No. 0920-0728
DEMOGRAPHIC DATA
1. Reporting
2. First three letters of
3. Date
or Age:
State:
patient’s last name:
of birth:
(in years)
Mo.
Day
Yr.
4. Sex:
5. Does the patient work as a foodhandler?
6. Citizenship:
Male
Female
Yes
No
Unk.
U.S.
Other:
Unk.
CLINICAL DATA
7. Was the patient ill with typhoid
8. Was the patient
If Yes, give date of
If Yes, how many days was
9. Outcome
or paratyphoid fever? (fever,
hospitalized?
onset of symptoms:
the patient hospitalized?
of case:
abdominal pain, headache, etc)
Recovered
Died
Yes
No
Unk.
Yes
No
Unk.
Unk.
Mo.
Day
Yr.
Days
LABORATORY DATA
10. Date Salmonella first isolated:
Site(s) of isolation:
(check all that apply)
Blood
Stool
Gall Bladder
Other (specify):
Mo.
Day
Yr.
Serotype:
Typhi
Paratyphi A
Paratyphi B
Paratyphi C
11. Was antibiotic sensitivity testing performed
{
• Ampicillin:
No
Not tested
Yes
on this (these) isolate(s) at the laboratory?
If Yes, was
Chlor
amphenicol:
(Please contact the clinical laboratory for
Not tested
Yes
No
the organism
this information)
• Trimethoprim-sulfamethoxazole:
Not tested
Yes
No
resistant to:
• Fluoroquinolones (e.g., Ciprofloxacin):
No
Not tested
Yes
Yes
No
Unk.
EPIDEMIOLOGIC DATA
12. Did this case occur as part of an outbreak?
(two or more cases of typhoid or paratyphoid fever associat
ed by time and place)
Yes
No
Unk.
{
Year received
13. Did the patient receive typhoid vaccination
(primary series or booster) within
• Oral Ty21a or Vivotif (Berna) four pill series:
If Yes,
Yes
No
Unk.
five years before onset of illness?
indicate type
of vaccine
Yes
No
Unk.
• ViCPS or Typhim Vi shot (Pasteur Merieux):
received:
No
Unk.
Yes
14. Did the patient travel or live outside
If Yes, please list in order the countries visited during the 30 days
Date of most recent return or
the United States during the 30 days
before the illness began: (other than the United States)
entry to the United States:
before the illness began?
1.
3.
Yes
No
Unk.
2.
4.
Mo.
Day
Yr.
15. Was the purpose of the international travel:
a. Business?
d. Immigration to U.S.?
Unk.
Unk.
Yes
No
Yes
No
b. Tourism?
e. Other?
No
Unk.
No
Unk.
Yes
Yes
c. Visiting relatives or friends?
Unk.
No
Yes
(if other, specify):
16. Was the case
If Yes, was the carrier previously
traced to a typhoid or paratyphoid carrier?
known to the health department?
Unk.
No
No
Unk.
Yes
Yes
17. Comments:
18. Name of Person
Completing Form:
Address:
Telephone:
Date:
Mo.
Day
Yr.
– THANK YOU VERY MUCH FOR TAKING THE TIME TO COMPLETE THIS FORM –
Please send a copy to your STATE EPIDEMIOLOGY OFFICE and the
Enteric Diseases Epidemiology Branch, Centers for Disease Control and Prevention
Mailstop C-09, Atlanta, Georgia 30333 • Fax: (404) 639-2205
Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0728).
TYPHOID AND PARATYPHOID FEVER SURVEILLANCE REPORT
CDC 52.5 (E), June 1997, Revised March 2007
PAGE 1 OF 1
CS246979
(CDC Adobe Acrobat 10.1, S508 Electronic Version, November 2012)
Print
Save Form