Measles Household Line Listing

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Household Line Listing

Measles

List Dates of HH Visits __ _/__ _/__ _ __ _/__ _/__ _ __ _/__ _/__ _ Household Location: Municipality _______________ Village _______________

Number of Rooms in the House ____ Number of Persons Living in the House _____

HH No.	First Name Last Name	Sex	Date of Birth	Age (y, m)	Mother’s First Name (If age 39 or less)	Fever and rash in the last 2 months (May/June)?	Had measles before this year?	MMR Doses	MMR Dates	Doses obtained (check one)	Lived/slept at least one night in the HH from 3 days prior and 3 days after rash onset of 1st case?
1			__ /_ __/_ __			Yes Date of onset __ _/__ _/__ _ No	Yes No	0___ 1___ 2___ 3___	__ _/_ __/_ __ __ _/_ __/_ __ __ _/_ __/_ __	__ by history __ from record	Yes No
2			__ /_ __/_ __			Yes Date of onset __ _/__ _/__ _ No	Yes No	0___ 1___ 2___ 3___	__ _/_ __/_ __ __ _/_ __/_ __ __ _/_ __/_ __	_ by history _ from record	Yes No
3			__ /_ __/_ __			Yes Date of onset __ _/__ _/__ _ No	Yes No	0___ 1___ 2___ 3___	__ _/_ __/_ __ __ _/_ __/_ __ __ _/_ __/_ __	_ by history _ from record	Yes No
4			__ /_ __/_ __			Yes Date of onset __ _/__ _/__ _ No	Yes No	0___ 1___ 2___ 3___	__ _/_ __/_ __ __ _/_ __/_ __ __ _/_ __/_ __	_ by history _ from record	Yes No
5			__ /_ __/_ __			Yes Date of onset __ _/__ _/__ _ No	Yes No	0___ 1___ 2___ 3___	__ _/_ __/_ __ __ _/_ __/_ __ __ _/_ __/_ __	_ by history _ from record	Yes No
6			__ /_ __/_ __			Yes Date of onset __ _/__ _/__ _ No	Yes No	0___ 1___ 2___ 3___	__ _/_ __/_ __ __ _/_ __/_ __ __ _/_ __/_ __	_ by history _ from record	Yes No
7			__ /_ __/_ __			Yes Date of onset __ _/__ _/__ _ No	Yes No	0___ 1___ 2___ 3___	__ _/_ __/_ __ __ _/_ __/_ __ __ _/_ __/_ __	_ by history _ from record	Yes No
8			__ /_ __/_ __			Yes Date of onset __ _/__ _/__ _ No	Yes No	0___ 1___ 2___ 3___	__ _/_ __/_ __ __ _/_ __/_ __ __ _/_ __/_ __	_ by history _ from record	Yes No
9			__ /_ __/_ __			Yes Date of onset __ _/__ _/__ _ No	Yes No	0___ 1___ 2___ 3___	__ _/_ __/_ __ __ _/_ __/_ __ __ _/_ __/_ __	_ by history _ from record	Yes No
10			__ /_ __/_ __			Yes Date of onset __ _/__ _/__ _ No	Yes No	0___ 1___ 2___ 3___	__ _/_ __/_ __ __ _/_ __/_ __ __ _/_ __/_ __	__ by history __ from record	Yes No
11			__ /_ __/_ __			Yes Date of onset __ _/__ _/__ _ No	Yes No	0___ 1___ 2___ 3___	__ _/_ __/_ __ __ _/_ __/_ __ __ _/_ __/_ __	_ by history _ from record	Yes No
12			__ /_ __/_ __			Yes Date of onset __ _/__ _/__ _ No	Yes No	0___ 1___ 2___ 3___	__ _/_ __/_ __ __ _/_ __/_ __ __ _/_ __/_ __	_ by history _ from record	Yes No
13			__ /_ __/_ __			Yes Date of onset __ _/__ _/__ _ No	Yes No	0___ 1___ 2___ 3___	__ _/_ __/_ __ __ _/_ __/_ __ __ _/_ __/_ __	_ by history _ from record	Yes No
14			__ /_ __/_ __			Yes Date of onset __ _/__ _/__ _ No	Yes No	0___ 1___ 2___ 3___	__ _/_ __/_ __ __ _/_ __/_ __ __ _/_ __/_ __	_ by history _ from record	Yes No
15			__ /_ __/_ __			Yes Date of onset __ _/__ _/__ _ No	Yes No	0___ 1___ 2___ 3___	__ _/_ __/_ __ __ _/_ __/_ __ __ _/_ __/_ __	_ by history _ from record	Yes No
16			__ /_ __/_ __			Yes Date of onset __ _/__ _/__ _ No	Yes No	0___ 1___ 2___ 3___	__ _/_ __/_ __ __ _/_ __/_ __ __ _/_ __/_ __	_ by history _ from record	Yes No
17			__ /_ __/_ __			Yes Date of onset __ _/__ _/__ _ No	Yes No	0___ 1___ 2___ 3___	__ _/_ __/_ __ __ _/_ __/_ __ __ _/_ __/_ __	_ by history _ from record	Yes No
18			__ /_ __/_ __			Yes Date of onset __ _/__ _/__ _ No	Yes No	0___ 1___ 2___ 3___	__ _/_ __/_ __ __ _/_ __/_ __ __ _/_ __/_ __	_ by history _ from record	Yes No

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