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24. UNDERLYING CAUSES OR PRIOR ILLNESSES: (Check all that apply OR if NONE or CHART UNAVAILABLE, check appropriate box) 1
1
1
1
1
AIDS or CD4 count <200
Alcohol Abuse
Asthma
Atherosclerotic Cardiovascular Disease
(ASCVD)/CAD
1
1
1
1
1
1
Bone Marrow Transplant (BMT)
Cerebral Vascular Accident (CVA)/Stroke
Chronic Renal Insufficiency
Chronic Skin Breakdown
Cirrhosis/Liver Failure
Cochlear Implant
1
1
1
1
1
1
1
1
1
1
1
Complement Deficiency
CSF Leak
Current Smoker
Deaf/Profound Hearing Loss
Dementia
Diabetes Mellitus
Emphysema/COPD
Heart Failure/CHF
HIV Infection
Hodgkin’s Disease/Lymphoma
Immunoglobulin Deficiency
None
1
Unknown
1
Immunosuppressive Therapy (Steroids,
Chemotherapy, Radiation)
1
1
1
1
1
1
1
1
1
1
1
IVDU
Leukemia
Multiple Myeloma
Multiple Sclerosis
Nephrotic Syndrome
Neuromuscular Disorder
Obesity
Parkinson’s Disease
Peripheral Neuropathy
Plegias/Paralysis
Premature Birth (specify gestational
age at birth)
(wks)
1
1
1
1
1
1
1
1
Renal Failure/Dialysis
Seizure/Seizure Disorder
Sickle Cell Anemia
Solid Organ Malignancy
Solid Organ Transplant
Splenectomy/Asplenia
Systemic Lupus Erythematosus (SLE)
Other prior illness (specify)
– IMPORTANT – PLEASE COMPLETE FOR THE RELEVANT ORGANISM –
INFLUENZA
25. Did this patient have a positive flu test 10 days prior to or following any ABCs positive culture?
HAEMOPHILUS
INFLUENZAE
DOSE
1
Yes
2
No
9
26a. If <15 years of age and serotype ‘b’ or ‘unknown’ did
1 Yes 2
No
9
Unknown
patient receive Haemophilus influenzae b vaccine?
If YES, please complete the list below.
DATE GIVEN
LOT NUMBER
VACCINE NAME
MANUFACTURER
Mo.
Day
Unknown
26b. Were records obtained to verify
vaccination history? (<5 years of age
with Hib/unknown serotype, only)
Year
1
1
Yes
2
No
2
If YES, what was the source of the
information? (Check all that apply)
3
1
Vaccine Registry
1
Healthcare Provider
1
Other (specify)
4
26c. What was the serotype?
1
b
2
Not Typeable
NEISSERIA MENINGITIDIS
27. What was the serogroup?
3
a
4
c
5
d
6
e
7
f
8
Other (specify)
A
3
C
5
W135
9
Unknown
2
B
4
Y
6
Not groupable
8
Other (specify)
1
Yes 2
No
9
Mo.
Day
VACCINE NAME
MANUFACTURER
1
Yes 2
No
9
Unknown
STREPTOCOCCUS PNEUMONIAE
30. Did patient receive pneumococcal vaccine?
Unknown
If YES, please complete the following information:
DATE GIVEN
Not Tested or Unknown
28. Is patient currently attending college?
(15 – 24 years only)
1
29. Did patient receive meningococcal vaccine?
DOSE
9
1
LOT NUMBER
Yes
2
No 9
Unknown
If YES, please note which pneumococcal vaccine was received:
(Check all that apply)
Year
1
2
1
Prevnar®, 7-valent Pneumococcal Conjugate Vaccine (PCV7)
1
Prevnar-13®, 13-valent Pneumococcal Conjugate Vaccine (PCV13)
1
Pneumovax®, 23-valent Pneumococcal Polysaccharide Vaccine (PPV23)
1
Vaccine type not specified
If between ≥3 months and <18 years of age and an isolate is available for
serotyping, please complete the Invasive Pneumococcal Disease in Children
expanded form.
3
(#31–33 refer to the 7 days
prior to first positive culture)
GROUP A STREPTOCOCCUS
1
31. Did the patient have surgery
or any skin incision?
Yes 2
Mo.
No
Day
9
32. Did the patient deliver a baby (vaginal or C-section)?
1
Unknown
Year
Yes 2
If YES,
date of delivery:
If YES, date of surgery or skin incision:
No
9
Mo.
33. Did patient have:
Unknown
Day
Year
1
Varicella
1
Penetrating trauma
1
Blunt trauma
1
Surgical wound
(post operative)
1
Burns
34. COMMENTS:
– SURVEILLANCE OFFICE USE ONLY –
35. Was case first
identified through
audit?
1
Yes 2
9
Unknown
No
36. CRF Status:
1
2
3
4
Complete
Incomplete
Edited & Correct
Chart unavailable
after 3 requests
37. Does this case have
recurrent disease with
the same pathogen?
1
Yes 2
9
Unknown
38. Date reported to EIP site:
If YES, previous
(1st) state I.D.:
Mo.
No
Submitted By:
Phone No. : (
)
Physician’s Name:
Phone No. : (
)
CDC 52.15A REV. 1-2012
– ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –
Day
39. Initials of
S.O.:
Year
Date:
/
/
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| File Type | application/pdf |
| File Modified | 2013-06-28 |
| File Created | 2013-05-21 |