Form no number no number ABCs Invasive Pneumococcal Disease in Children Form

Patient’s Name __________________ Patient’s Date of Birth ___/__/____

ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs)

INVASIVE PNEUMOCOCCAL DISEASE IN CHILDREN

Revised 10/24/2003

StateID: __ __ __ __ __ __ __

Date of positive culture ____/____/_____ Date form completed ____/____/_____

- VACCINE HISTORY -

• Child has never received vaccines

• Vaccination history unknown

VACCINES	Dose #	Dates of immunizations	Manufacturer	Vaccine name	Lot #
Pneumococcal conjugate vaccine (Prevnar®)	1
	2
	3
	4
Pneumococcal polysaccharide vaccine (Pneumovax® 23)	1
	2
Diphtheria/Tetanus/ Pertussis (DTP or DtaP)	1
	2
	3
	4
	5
Haemophilus influenza type B (Hib)	1
	2
	3
	4
Influenza vaccine	1
	2
	3

*For combination vaccines (e.g. Trihibit, Tetramune, ActHIB/DTwP) enter information for each vaccine component

- IMMUNE SYSTEM EVALUATION-

Does this patient have an immune disorder other than HIV or AIDS? □ Yes □ No □ Unknown

If yes, diagnosis _________________________

If yes, indicate below results for any tests performed to evaluate immune function:

Tests Test Date Result

IgGtotal..……………___/___/_____ □ Low □ Normal □ High □ Not done

IgG1…………………___/___/_____ □ Low □ Normal □ High □ Not done

IgG2…………………___/___/_____ □ Low □ Normal □ High □ Not done

IgG3…………………___/___/_____ □ Low □ Normal □ High □ Not done

IgG4…………………___/___/_____ □ Low □ Normal □ High □ Not done

IgM………………….___/___/_____ □ Low □ Normal □ High □ Not done

IgA…………………..___/___/_____ □ Low □ Normal □ High □ Not done C3……………………___/___/_____ □ Low □ Normal □ High □ Not done

C4……………………___/___/_____ □ Low □ Normal □ High □ Not done

CH50………………...___/___/_____ □ Low □ Normal □ High □ Not done

Other (specify_____________)___/___/_____ □ Low □ Normal □ High □ Not done

Other (specify_____________)___/___/_____ □ Low □ Normal □ High □ Not done

Person completing the form (please print): Phone: ( )______________

Name ___________________Title ___________ Fax: ( )______________

Please return ______________________ Phone: ( )______________

form to: ______________________ Fax: ( )______________

______________________