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Cities - Reporting

ICR 201606-0920-001 · OMB 0920-0728 · Object 65217401.
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File Type	application/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Title	Cities - Reporting
Author	Aranas
Last Modified By	Calc
File Modified	2016-06-01
File Created	2026-07-22
Conversion State	complete
Extracted Text

Attachment 7: Disease-Specific Data
Subsequent tabs in this workbook describe the disease-specific data elements that are requested from each program area.

Label/Short Name

Description

AnimalID
Date Collected
Species
Sex
Age
Vax Status
Human Exposure
Animal Exposure

Unique ID for animal submitted for rabies diagnosis
Date animal collected for rabies diagnosis
Species of animal submitted for rabies diagnosis
Sex of animal
Age category of animal
Rabies vaccination status of animal submitted for rabies diagnosis
Was there a potential human exposure to the animal submitted
Was there a potential domestic animal exposure ot the animal submitted

Latitude
Longitude
Address
City
County
State
ZipCode
DFAResult
Date DFA
DRIT Result
Date DRIT
Variant
DateTyped

Latitutde of Animal Collection
Longitude of animal collection
Street Address of animal collection
City of animal collection
County of animal collection
State of animal collection
Zip Code of animal collection
Results of direct flourescent antibody test
Date tested by DFA
Results of direct rapid immunohistochemistry test
Date tested by DRIT
Rabies virus variant if typed
Date rabies virus typed

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

PHVS_AnimalSpecies_AnimalRabies
PHVS_Sex_MFU
PHVS_AnimalAgeCategory_NND
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_City_USGS_GNIS
PHVS_County_FIPS_6-4
PHVS_State_FIPS_5-2
PHVS_PosNegUnk_CDC
PHVS_PosNegUnk_CDC
PHVS_VirusVariantType_AnimalRabies

Label/Short Name
Case Class Status Code
Case Status Determined
State
State Case ID
Date State Notified
County reporting the case
Date local health department
notified
Person Reporting to CDC - Name

Person Reporting to CDC - Phone
Number
Treating HCP
HCP Phone
MMWR year
Event date
Event Type
Subject’s Sex
Pregnancy status
Date of Birth
Age at case investigation
Age units at case investigation
Country of usual residence
Occupation
Date Onset
Subject Address County
Date Diagnosis
Clinical presentation
Hospitalized
Final treatment place
Admission Date
ICU
Mechanical ventilation
AIG
Raxibacumab
Outcome

Discharge Date
Deceased Date
Autopsy
Reporting Lab Name
Date Laboratory diagnosis
Date Sample Received at Lab
Date of Acute Specimen Collection
Date of Convalscent Specimen
Collection
Resulted Test Name
Numeric Result
Result Units
Coded Result Value
Organism Name
Lab Result Text Value
Result Status
Specimens to CDC
Interpretation Flag

Exposure event
Exposure response
Exposure to animals
Exposure to animals products
Contact with undercooked meat
Gardened
Bone meal
Laboratory work
Unknown powder
Suspicious mail
Similar illness
Similar food contact
Similar exposures
Illicit drugs
Received injection
Took public transportation
Transportation type
Other transportation
Attended gathering
Congregate
Travel

Latitude
Longitude
Vaccine
Vaccine received

Vaccine dose
Post exposure antibiotics
Antibiotics not taken
Antibiotics not taken specify

Description
Status of the case/event as suspect, probable, confirmed, or not a case per CSTE/CDC/
surveillance case definitions.
How was the case status determined, from "Laboratory Results", "Clinical
Presentation", "Epi Link"
State reporting case
States use this field to link NEDSS investigations back to their own state investigations.
Date State Notified
County reporting the case
Date local health department notified
Name of the person who is reporting the case to the CDC. This is the person that CDC
should contract in a state if there are questions regarding this case notification.
Phone Number of the person who is reporting the case to the CDC. This is the person
that CDC should contract in a state if there are questions regarding this case
notification.
Name of the treating health care provider of the subject
Telephone number of the treating health care provider of the subject
MMWR year of report
Event Date ( earliest date associated with case)
Event Type from "Date Onset", "Date Diagnosis", "Date State Notified", "Date LHD
notified", "Date Laboratory diagnosis"
Subject’s current sex
Indicates whether the subject was pregnant at the time of the event.
Birth Date (mm/yyyy)
Subject age at time of case investigation
Subject age units at time of case investigation
Country of usual residence
Provide the subject's occupation
Date Onset
County of residence of the subject
Date Diagnosis
Clinical Presentation (Cutaneus, Inhalation, Meningitis, GI/Oroph, Injection)
Was subject hospitalized because of this event?
List the place of final treatment (only to be sent during a bioterrorism event)
Subject’s first admission date to the hospital for the condition covered by the
investigation.
Was the subject admitted to Intensive Care Unit for any length of time?
Was the subject on mechanical ventilation for any length of time?
Did the subject receive Anthrax anti-toxin?
Did the subject receive raxibacumab?
Clinical outcome of the patient ("Still hospitalized"; "Discharged"; "Died";"Other")

Subject's first discharge date from the hospital for the condition covered by the
investigation.
If the subject died from this illness or complications associated with this illness,
indicate the date of death
If the subject died, was an autopsy performed?
Name of Laboratory that reported test result.
Date Laboratory diagnosis
Date Sample Received at Lab (accession date).
The date the acute specimen was collected.
The date the convalscent specimen was collected.
The lab test that was run on the specimen
Results expressed as numeric value/quantitative result.
The unit of measure for numeric result value.
Coded qualitative result value (e.g., Positive, Negative).
The organism name as a test result. This element is used when the result was reported
as an organism.
Textual result value, used if result is neither numeric nor coded.
The Result Status is the degree of completion of the lab test.
Were specimens or isolates sent to CDC for testing?
The interpretation flag identifies a result that is not typical as well as how it's not
typical. Examples: Susceptible, Resistant, Normal, Above upper panic limits, below
absolute low.
If participated in a documented exposure event, give the name or location
Participated in exposure response?
Exposure to livestock/ wild mammals/ their body fluids?
Exposure to animal products?
Consumed or contact with undercooked or raw meat?
Gardened or other work with soil?
If yes, was bone meal fertilizer or similar used?
Worked in a clinical or microbiological laboratory?
Exposed to unknown powder?
Handled suspicious mail?
Undiagnosed similar illness in friends, family, coworkers, or other contacts?
Consumed same food/drink as lab-confirmed anthrax case?
Exposed to the same environment, animal, or objects as a lab-confirmed anthrax case?
Contact with illicit drugs?
Received an injection?
Took public transportation?
If Took public transportation is "Yes", what form of transportation did the subject take
("Bus"; "Train";"Light rail"; "Subway"; "Ferry"; "Other")
If the patient took Other form of public transportation, describe
Attended a large gathering (e.g., concert, sporting event)?
Attended a place where people congregate (e.g., shopping mall, relgious services)?
Traveled out of county, state, or country?

Latitude of suspected exposure location (only to be sent during a bioterrorism event)
Longitude of suspected exposure location (only to be sent during a bioterrorism event)
Was anthrax vaccine received?
If anthrax vaccine received is "Yes", specify what was received from "Post-exposure
vaccine (1,2,or 3 doses)", "Partial series of pre-exposure vaccine", "Full series of preexposure vaccine"
If anthrax vaccine received is "Yes" specify the number of doses received or vaccination
status, from "1", "2", "3", "<5", "Outdated on annual boosters", "Fully updated on
annual boosters", "Unknown"
Received Post-Exposure Antibiotics
Antibiotics not taken or discontinued?
If Antibiotics were not taken or were discontinued is "Yes", select the primary reason
why they were not taken "Low perceived risk", "Adverse events", "Fear of side effects",
"Other", "Unknown"

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
PHVS_CaseClassStatus_NND

PHVS_State_FIPS_5-2

PHVS_County_FIPS_6-4

PHVS_Sex_MFU
PHVS_YesNoUnknown_CDC

PHVS_AgeUnit_UCUM_NETSS
PHVS_CountryofBirth_CDC

PHVS_County_FIPS_6-4

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_LabTestName_CDC
PHVS_UnitsOfMeasure_CDC
PHVS_PosNegUnk_CDC
PHVS_Microorganism_CDC
PHVS_ObservationResultStatus_HL7_2x
PHVS_YesNoUnknown_CDC
PHVS_AbnormalFlag_HL7_2x

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

Label/Short Name
StateID
Year
State
County
Week
OnsetDate
ImportedFrom
CountryOfOrigin
StateOfOrigin
ForeignResident
Arbovirus
CaseStatus
Age
AgeUnit
BirthDate
Sex
Race
Ethnicity
ClinicalSyndrome
Fever
Headache
Rash
NauseaVomiting
Diarrhea
Myalgia
ArthralgiaArthritis
ParesisParalysis
StiffNeck
AlteredMentalStatus
Seizures
StateLocalPublicHealthLab
CDCLab
CommercialLab
Serum1Collected
Serum1CollectedDate
Serum2Collected
Serum2CollectedDate
CSFCollected
CSFCollectedDate
CSFPLeocytosis
SerumIgM
SerumPRNT
SerumPCRorNAT

SerumPairedAntibody
CSFIgM
CSFPRNT
CSFPCRorNAT
Hospitalized
Fatality
DateOfDeath
LabAcquired
NonLabAcquired
BloodDonor
BloodTransfusion
OrganDonor
OrganTransplant
BreastFedInfant
InfectedInUteroOrPerinatal
Pregnant
AFP
IdentifiedByBloodDonorScreening
DateOfDonation
LabTestingBy
TransmissionOrigin
TransmissionMode
BloodTissueBorneTransmission
DomesticTravelDestinationLast
DomesticTravelDestination2ndLast
DomesticTravelDestination3rdLast
ForeignTravelDestinationLast
ForeignTravelDestination2ndLast
ForeignTravelDestination3rdLast
DateUSReturn
DurationDaysTravelOutsideUS
ReasonTravel
PreTravelHealthConsultation
CountryBirth
ResidenceStatus
DurationMonthsVisitOrLiveUS
MilitaryStatus
ClinicalSyndrome2
DurationDaysHospitalized
ICUAdmission
SevereEncephalitis
SevereSeizure
SevereMeningitis

SevereAcuteFlaccidParalysis
SevereGuillainBarreSyndrome
SevereHemorrhageShock
SeverePlasmaLeakage
SevereAcuteLiverFailure
SevereAcuteMyocarditis
SevereMultiSystemOrganFailure
SevereOtherSevereSigns
SevereUnknown
PreExistingAsthma
PreExistingChronicHeart
PreExistingChronicLiver
PreExistingChronicRenal
PreExistingDiabetesMellitus
PreExistingSickleCell
PreExistingHyperlipidemia
PreExistingHypertension
PreExistingObesity
PreExistingPregnancy
PreExistingThyroidDisease
PreExistingOther
PreExistingUnknown
S1DENVCollected
S1DENVCollectedDate
S1IgMAntiDENV
S1MolecularDENV
S1OtherDENVMethod
S1OtherDENVResult
S2DENVCollected
S2DENVCollectedDate
S2IgMAntiDENV
S2MolecularDENV
S2OtherDENVMethod
S2OtherDENVResult
OtherSpecCollected
OtherSpecType
OtherSpecCollectedDate
OtherSpecDENVMethod
OtherSpecDENVResult
DENVSeroType
Published
FeverMedication
ImmuneSuppressTreatment
ImmuneSuppressCondition
ImmuneSuppressDesc

OtherAfebrileCause
ChillsRigors
FatigueMalaise
Ataxia
ParkinsonismCogwheel
SevereShock
SevereHemorrhage
OtherSymptoms
Arthralgia
Arthritis
Conjunctivitis
RetroOrbitalPain
TourniquetTestPositive
Leukopenia
AbdominalPainTenderness
PersistingVomiting
ExtravascularFluidAccumulation
MucosalBleeding
LiverEnlargement
IncreasingHematocritDecPLT
SevereBleeding
SevereOrganInvolvement

Description
State-assigned investigation identification code
Current year (new)
State of residence
County of residence
Week of report (new)
Date of onset of symptoms consistent with arboviral infection
Likely location of acquisition of arboviral infection
Country in which infection was likely acquired
State in which infection was likely acquired
(New)
Type of arboviral infection
Case classification according to CDC/CSTE surveillance case definitions
Age at time of case investigation
Age units
Date of Birth
Current sex
Race
Ethnicity
General clinical presentation
Clinical Sign/Symptom
Clinical Sign/Symptom
Clinical Sign/Symptom
Clinical Sign/Symptom
Clinical Sign/Symptom
Clinical Sign/Symptom
Clinical Sign/Symptom
Clinical Sign/Symptom
Clinical Sign/Symptom
Clinical Sign/Symptom
Clinical Sign/Symptom
Testing performed at:
Testing performed at:
Testing performed at:
Was Serum1 collected?
When was Serum1 collected?
Was Serum2 collected?
When was Serum2collected?
Was CSF collected?
When was CSF collected?

Patient was hospitalized as a result of arboviral illness
Patient died as a result of arboviral infection
Date of death
Patient likely acquired infection due to occupational exposure in a laboratory setting
Patient likely acquired infection due to occupational exposure in a non-laboratory
setting
Patient donated blood within 30 days prior to illness onset
Patient received a blood transfusion within 30 days prior to illness onet
Patient donated a solid organ within 30 days prior to illness onset
Patient received a solid organ transplant within 30 days prior to illness onset
Patient was a breastfed infant at time of illness onset
Patient likely acquired infection in utero or perinatal
Patient acquired infection during pregnancy
Patient suffered acute flaccid paralysis
Infection identified through blood donor screening
Date of blood donation
Source of diagnostic testing

Did patient receive medication for fever?
Is patient on immunosuppressive therapy?
Does patient have an immunosuppressive condition?
Description of immunosuppressive condition

Other afebrile causes
Did patient have chills or rigors?
Did patient exhibit fatigue or malaise?
Did patient have ataxia?
Was Parkinsonism cogwheel rigidity present?
Did patient exhibit severe shock?
Did patient have severe hemorrhaging?
Other symptoms of interest
Did patient exhibit arthralgia?
Did patient exhibit arthritis?
Did the patient have conjunctivitis?
Did the patient have retro orbital pain?
Did the patient have a tourniquet test positive?
Did the patient have leukopenia?
Did the patient have abdominal pain tenderness?
Did the patient have persisting vomiting?
Did the patient have extravascular fluid accumulation?
Did the patient have mucosal bleeding?
Did the patient have liver enlargement?
Did the patient have increasing hematocrit dec PLT?
Did the patient have severe bleeding?
Did the patient have severe organ involvement?

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

Label/Short Name
Date Submitted
Clinician Name
Clinician Phone
Symptomatic
ClinicalManifestation
Asplenic
Reason for Splenectomy
Date of Splenectomy
Symptoms
Symptom Fever
Temperature
Temperature Units
Symptom Headache
Symptom Myalgia
Symptom Anemia
Symptom Chills
Symptom Arthralgia
Symptom Thrombocytopenia
Symptom Sweats
Symptom Nausea
Symptom Hepatomegaly
Symptom Splenomegaly
Symptom Cough
Symptoms Other
Complications
Risk Factor Immunosuppressed
Risk Factor Immune Condition
Hospitalization
Death Related to Babesiosis
Treatment
Treatment Medications
Transfusion Associated Recipient
Transfusion Associated Donor
Outdoor Activities
Outdoor Activities Type
Occupation
Wooded Areas
History of Babesiosis
Date of Previous Babesiosis

Tick Bite
Tick Bite Date
Tick Bite Place
Travel
Travel Date
Travel Place
Infected In Utero
Mother Test Positive After Delivery
Mother Test Positive Before Delivery
Mother Confirmed Positive Date
Blood Donor Screening

Blood Donor
Date of Donation
Linked Recipient
Blood Recipient
Date of Transfusion
Implicated Product
Linked Donor
Organ Donor
Organ Transplant
Lab Test
Date of Specimen Collection
Lab
Coded Result
Numeric Result
Babesia Species
Parasitemia
Confirmed SPHL
Date of Onset Approx
Date of Death Approx
Date Approx
Case Classification

Description
Date the case report form (extended variables) was submitted to CDC
Name of treating clinician
Phone number for treating clinician
Was the case-patient symptomatic?
Did the case-patient have any clinical manifestations of babesiosis?
Is the case-patient asplenic?
Why was the case-patient's spleen removed?
Date of splenectomy
Indicate case-patient's signs and symptoms
Did the case-patient have a fever?
If fever was indicated, specify temperature (observation includes units)
If fever was indicated, specify Fahrenheit or Celsius
Did the case-patient have a headache?
Did the case-patient have myalgia?
Did the case-patient have anemia?
Did the case-patient have chills?
Did the case-patient have arthralgia?
Did the case-patient have thrombocytopenia?
Did the case-patient have sweats?
Did the case-patient have nausea?
Did the case-patient have hepatomegaly?
Did the case-patient have splenomegaly?
Did the case-patient have a cough?
Indicate any additional symptoms or clinical manifestations
Select all complications
At the time of diagnosis, was the case-patient immunosuppressed?
If the case-patient reported being immunosuppressed, what was the cause?
If the case-patient was hospitalized, indicate the length in days of the hospitalization.
Was the case-patient's death related to the Babesia infection?
Did the case-patient receive antimicrobial treatment for Babesia infection?
If the case-patient was treated, specify which drugs were administered.
Was the case-patient’s infection transfusion associated?
Was the case-patient a blood donor identified during a transfusion investigation?
In the eight weeks before symptom onset or diagnosis (use earlier date), did the casepatient engage in outdoor activities?
Specify outdoor activities
Indicate case-patient's occupation
In the eight weeks before symptom onset or diagnosis (use earlier date), did the casepatient spend time outdoors in or near wooded or brushy areas?
Does the case-patient have a previous history of babesiosis in the last 12 months (prior
to this report)?
Date of previous babesiosis diagnosis

In the eight weeks before symptom onset or diagnosis (use earlier date), did the casepatient notice any tick bites?
When did the tick bite occur (approximate dates accepted)?
Where (geographic location) did the tick bite occur (city, state, country)?
In the eight weeks before symptom onset or diagnosis (use earlier date), did the casepatient travel (check all that apply)?
When did the travel occur?
Where did the case-patient travel (city, state, country)?
Was the case-patient an infant born to a mother who had babesiosis or Babesia
infection during pregnancy?
Did the case-patient's mother test positive for babesiosis after delivery?
Did the case-patient's mother test positive for babesiosis before or at the time of
delivery?
Date of mother's earliest positive test result
Donors who have been identified as having a Babesia infection through routine blood
donor screening (e.g., IND) by the blood collection agency. May or may not be
symptomatic.
Did the case-patient donate blood in the 8 weeks prior to onset?
Date of blood donation(s)
Was a transfusion recipient(s) identified for the case-patient's donation?
Did the case-patient receive a blood transfusion in the 8 weeks prior to onset?
Date of blood transfusion(s)
If a blood product was implicated, specify which type of product.
Was a blood donor identified for the case-patient's transfusion?
Did the case-patient donate an organ in the 30 days prior to onset?
Did the case-patient receive an organ in the 30 days prior to onset?
Indicate each test performed (repeat variables as necessary).
Provide the date the specimen was collected
Information on whether the specimen was tested in public health labs or exclusively in
commercial laboratories.
Coded qualitative result value (e.g., positive, negative).
Results expressed as numeric value/quantitative result (e.g., titer).
Provide species identified by the laboratory test (if applicable).
Estimated number of infected erythrocytes expressed as a percentage of the total
erythrocytes.
Was the diagnosis confirmed at the state public health laboratory?
If exact date of illness onset is not known, provide approximate date (mm/yyyy).
If exact date of death is not known, provide approximate date (mm/yyyy).
Is the date provided an approximation?
Indicate the case classification status (confirmed, probable, suspect, unknown)

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_TemperatureUnit_UCUM
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_LabTestName_Babesiosis

PHVS_PosNegUnkNotDone_CDC
PHVS_LabResult_Babesiosis

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

Label/Short Name
Botulism Lab Confirmed
C. Botulinum Isolated
Botulinum toxin Isolated
Toxin Type Clin
Transmission Category
Botulism Food Source Code
Botulism Food Source Other
Food Tested
Food Tested Method
Food Botulism Positive
Food Bot Positive_Specify
Food Toxin Type Code
Food Toxin Type Other
Non-food Vehicle
Botulism Other Indicator
Botulism Laboratory Confirmed
Epi-linked
Comments
Reporting Lab Name
Reporting Lab CLIA Number
Local record ID (case ID)

Filler Order Number
Ordered Test Name

Date of Specimen Collection
Specimen Site
Specimen Number
Specimen Source
Specimen Details
Date Sample Received at Lab
Sample Analyzed date
Lab Report Date
Report Status
Resulted Test Name

Numeric Result
Result Units
Coded Result Value
Organism Name
Lab Result Text Value
Result Status
Interpretation Flag

Reference Range From
Reference Range To
Test Method
Lab Result Comments

Date received in state public health
lab
Track Isolate
Patient status at specimen collection
Isolate received in state public health
lab
Reason isolate not received
Reason isolate not received (Other)
Date received in state public health
lab
State public health lab isolate id
number
Case confirmed at state public health
lab
Case confirmed at CDC lab

Description
Was botulism laboratory confirmed from patient specimen?
Was C. botulinum/ C. baratii/ or C. butyricum isolated in culture from patient
specimen?
Was botulinum toxin confirmed from patient specimen?
If clinical specimen positive, what was its toxin type?
What was the transmission category (e.g., foodborne, wound, infant, other/unknown)?
If food is known or thought to be the source, please specify food type:
If “Other,” please specify other food type:
Was food tested?
The technique or method used to perform the test and obtain the test results.
Examples: Serum Neutralization, Titration, dipstick, test strip, anaerobic culture.
Was food positive for botulism?
If food positive, what was the food item?
If food was positive, what was its toxin type?
If “Other,” please specify other toxin type:
If not foodborne botulism, what was the vehicle/exposure (e.g., black tar heroin)
Does the patient have Other Clinical based Botulism?
Was botulism laboratory confirmed from patient specimen?
If botulism not laboratory confirmed from patient specimen or food, was case epilinked to a confirmed botulism case?
Space to add in general comments
Name of Laboratory that reported test result.
CLIA (Clinical Laboratory Improvement Act) identifier for the laboratory that performed
the test.
Sending system-assigned local ID of the case investigation with which the subject is
associated. This field has been added to provide the mapping to the case/investigation
to which this lab result is associated. This field should appear exactly as it appears in
OBR-3 of the Case Notification.
A laboratory generated number that identifies the test/order instance.
Ordered Test Name is the lab test ordered by the physician. It will always be included
in an ELR, but there are many instances in which the user entering manual reports will
not have access to this information.
The date the specimen was collected.
This indicates the physical location, of the subject, where the specimen originated.
Examples include: Right Internal Jugular, Left Arm, Buttock, Right Eye, etc.
A laboratory generated number that identifies the specimen related to this test.
The medium from which the specimen originated. Examples include whole blood,
saliva, urine, etc.
Specimen details if specimen information entered as text.
Date Sample Received at Lab (accession date).
The date and time the sample was analyzed by the laboratory.
Date result sent from Reporting Laboratory.
The status of the lab report.
The lab test that was run on the specimen.

Results expressed as numeric value/quantitative result.
The unit of measure for numeric result value.
Coded qualitative result value (e.g., Positive, Negative).
The organism name as a test result. This element is used when the result was reported
as an organism.
Textual result value, used if result is neither numeric nor coded.
The Result Status is the degree of completion of the lab test.
The interpretation flag identifies a result that is not typical as well as how it's not
typical. Examples: Susceptible, Resistant, Normal, Above upper panic limits, below
absolute low.
The reference range from value allows the user to enter the value on one end of a
expected range of results for the test. This is used mostly for quantitative results.
The reference range to value allows the user to enter the value on the other end of a
valid range of results for the test. This is used mostly for quantitative results.
The technique or method used to perform the test and obtain the test results.
Examples: Serum Neutralization, Titration, dipstick, test strip, anaerobic culture.
Comments having to do specifically with the lab result test. These are the comments
from the NTE segment if the result was originally an Electronic Laboratory Report.
Date the isolate was received in state public health laboratory.
Track Isolate functionality indicator
Patient status at specimen collection
Isolate received in state public health lab
Reason isolate not received
Reason isolate not received (Other)
Date received in state public health lab
State public health lab isolate id number
Case confirmed at state public health lab
Case confirmed at CDC lab

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_BotulismFoodSourceType_FDD
PHVS_YesNoUnknown_CDC
Should include mouse bioassay, PCR, ELISA, Culture
PHVS_YesNoUnknown_CDC
PHVS_BotulinumToxinType_FDD

PHVS_YesNo_HL7_2x
PHVS_YesNoUnknown_CDC

PHVS_BodySite_CDC

PHVS_Specimen_CDC

PHVS_ResultStatus_HL7_2x
PHVS_LabTestName_CDC

PHVS_UnitsOfMeasure_CDC
PHVS_LabTestResultQualitative_CDC
PHVS_Microorganism_CDC

PHVS_ObservationResultStatus_HL7_2x
PHVS_AbnormalFlag_HL7_2x

PHVS_LabTestMethods_CDC Should include mouse bioassay, PCR, ELISA, Culture

PHVS_TrueFalse_CDC
PHVS_PatientLocationStatusAtSpecimenCollection
PHVS_YesNoUnknown_CDC
PHVS_IsolateNotReceivedReason_NND

PHVS_YesNoUnknown_CDC

Label/Short Name
Specimen Number
Date First Submitted
Case Outbreak indicator
Source of Infection

Outbreak source
State Case ID
Health care provider
Local Subject ID
Health care provider
Person Reporting to CDC - Name

Person Reporting to CDC - Phone
Number
Subject Address State
Subject Address County
Age at case investigation
Age units at case investigation
Subject’s Sex
Pregnancy status
Country of Birth
Ethnic Group Code
Race Category

Occupation
Case Class Status Code
Stage of disease
Fever
Fever onset date
Maximum temperature
Temperature Units
Sweats
Sweats onset date
arthralgia
arthragia onset date
headache

headache onset date
Fatigue
Fatigue date of onset
Anorexia
Anorexia Onset date
Myalgia
Myalgia onset date
weight loss
weight loss onset date
endocarditis
endocarditis onset date
Orchitis
Orchitis onset date
Epididymitis
Epididymitis onset date
Hepatomegaly
Hepatomegaly onset date
splenomegaly
splenomegaly onset date
Arthritis
Arthritis onset date
Meningitis
Meningitis onset date
spondylitis
spondylitis onset date
Symptoms Other
Symptoms Other details
Symptoms Other onset date
Hospitalized
Admission Date
Discharge Date
Subject Died
Deceased Date

Treatment status
Treated doxycycline
Dose of doxycycline
Days of doxycycline
Treated with rifampin
dosage of rifampin
days of rifampin
Treated with streptomycin
dosage of streptomycin

days of streptomycin
treated with other drug 1
name of other drug 1
dose of other drug 1
Days other drug 1
treated with other drug 2
name of other drug 2
dose of other drug 2
Days other drug 2
treated with other drug 3
name of other drug 3
dose of other drug 3
Days other drug 3
Travel
travel location 1
Travel departure date 1
Travel return date 1
travel location 2
Travel departure date 2
Travel return date 2
Animal Contact
Birthing product animal
Birthing product animal other
Skinning contact with animal
Skinning contact with other animal
Hunt animal contact
Hunt other animal
Animal Other Contact Type

Other Animal Contact
Other animal contact
Birthing product own animal
Skinning contact owned
Hunt own animal
Other animal owned

Consumed meat or dairy
Milk animal source
Milk Animal other
Cheese
Other animal source of cheese
Meat animal source
Meat animal other
Food product other
Food product animal source
Food Animal other
Milk source country
Milk source other 1
Milk source other 2
Cheese source country
Country cheese was from 1
Country cheese was from 2
Meat source country
Meat source other 1
Meat source other 2
Food product source country
Food source other 1
Food source other 2
Is this case epi-linked to a laboratory
Similar illness

Close contact
Close contact Other
Exposure to Brucella
Location of Exposure
Location of Exposure, other
Risk of exposure
Exposure to Brucella vaccine
PEP received

no PEP was taken
no PEP was taken other
Complete PEP
Partial PEP
Earliest Date Reported to State
Reporting Lab Name
Reporting Lab City
Reporting Lab State
Reporting Lab Zip
Received from
Received city
Received state
Date Sample Received at Lab
Agglutination test name
Acute total titer
Convalscent total titer
Positive Result
Agglutination cut off
Acute IgG titer Agglutination
Convalscent IgG titer Agglutination
Agglutination Positive Result
ELISA test name
Acute IgG ELISA titer
Convalscent IgG ELISA titer
ELISA IgG Positive Result
Acute IgM ELISA titer
Convalscent IgM ELISA titer
ELISA IgM Positive Result
ELISA test cut off
Date of Acute Serum Specimen
Collection
Date of Convalscent Serum Specimen
Collection
Rose Bengal titer
Rose Bengal positive result
Rose Bengal test cut off
Coombs Titer
Coombs Titer positive result
Coombs test cut off
Other serologic test name 1

Other serologic test titer or value 1
Other serologic test 1 positive
Other serologic test 1 cut off
Other serologic test name 2
Other serologic test value 2
Other serologic test 2 positive
Other serologic test 2 cut off
PCR
PCR other specimen
Date specimen for PCR collected
PCR positive
PCR Species identified
Culture
Culture other specimen
Date specimen for culture was
collected
Culture positive
Culture Species identified
Pre antimicrobials
Select Agent Reporting
Lab exposure
Exposure reported
Specimens to CDC
Specimens still avaialble

Description
A laboratory generated number that identifies the specimen related to this test.
Date/time the notification was first sent to CDC. This value does not change after the
original notification.
Denotes whether the reported case was associated with an identified outbreak.
What is the source of infection from list "naturally-acquired", "lab-aquired",
"bioterrorism"
If case outbreak indicator is "Yes", what was the common exposure source, including
"Food consumption", "Occupational exposure", "Recreational exposure", "Family",
"Close contact", "Sexual contact"
States use this field to link NEDSS investigations back to their own state investigations.
Health care provider name
The local ID of the subject/entity.
Health care provider phone number
Name of the person who is reporting the case to the CDC. This is the person that CDC
should contract in a state if there are questions regarding this case notification.
Phone Number of the person who is reporting the case to the CDC. This is the person
that CDC should contract in a state if there are questions regarding this case
notification.
State of residence of the subject
County of residence of the subject
Subject age at time of case investigation
Subject age units at time of case investigation
Subject’s current sex
Indicates whether the subject was pregnant at the time of the event.
Country of Birth
Based on the self-identity of the subject as Hispanic or Latino
Field containing one or more codes that broadly refer to the subject’s race(s).
Occupation of the case patient, from list "Animal Research", "Medical Research",
"Dairy", "Laboratory", "Wildlife", "Rancher", "Slaughterhouse", "Tannery/rendering",
"Veterinarian/Vet Tech", "Lives w/person of with an occupation listed here", "Other"
Status of the case/event as suspect, probable, confirmed, or not a case per CSTE/CDC/
surveillance case definitions.
Stage of disease, inlcuding "Acute", "Subacute", "Chronic", "Unknown"
Did patient have a fever?
Onset date of fatigue
Maximum temperature reported
Specify fahrenheit or celsius
Experienced sweats
Onset date of sweats
Experienced arthralgia?
Onset date of arthralgia
Experienced headache

Onset date of headache
Experienced fatigue
Onset date of fatigue
Experienced anorexia
Onset date of anorexia
Experienced myalgia
Onset date of myalgia
Experienced weight loss
Onset date of weight loss
Experienced endocarditis?
Onset date of endocarditis
Experienced orchitis
Onset date of orchitis
Experienced epididymitis?
Onset date of epididymitis
Experienced hepatomegaly
Onset date of hepatomegaly
Experienced splenomegaly
Onset date of splenomegaly
Experienced athritis?
Onset date of arthritis
Experienced meningitis
Onset date of meningitis
Experienced spondylitis
Onset date of spondylitis
Were other symptoms or signs experienced
Describe other symptoms or signs experienced
Details of other symptoms experienced
Was subject hospitalized because of this event?
Subject’s first admission date to the hospital for the condition covered by the
investigation.
Subject's first discharge date from the hospital for the condition covered by the
investigation.
Did the subject die from this illness or complications of this illness?
If the subject died from this illness or complications associated with this illness,
indicate the date of death
Status of treatment at time of case notification ("Currently under treatment",
"Completed treatment", "Not treated", "No Response")
treated with doxycycline?
dosage of doxycycline prescribed
days of doxycycline prescribed
treated with rifampin?
dosage of rifampin prescribed
days of rifampin prescribed
treated with streptomycin?
dosage of streptomycin prescribed

days of streptomycin prescribed
treated with other drug 1?
If Other drug 1 is "Yes", list name of the drug
If Other drug 1 is "Yes", list the prescribed dosage of this drug
If Other drug 1 is "Yes", list the prescribed duration of this drug
treated with other drug 2?
If Other drug 2 is "Yes", list name of the drug
If Other drug 2 is "Yes", list the prescribed dosage of this drug
If Other drug 2 is "Yes", list the prescribed duration of this drug
treated with other drug 3?
If Other drug 3 is "Yes", list name of the drug
If Other drug 3 is "Yes", list the prescribed dosage of this drug
If Other drug 3 is "Yes", list the prescribed duration of this drug
In the 6 months prior to illness onset did the subject travel outside of the state of
residence?
Location of travel 1
If traveled, departure date to first destination
If traveled, return date from first destination
Location of travel 2
If traveled, departure date to second destination
If traveled, return date from second destination
In the 6 months prior to illness onset, did the subject have animal contact?
Which animal(s) did case patient have contact with birthing products ("Cow", "Pig",
"Goat", "Sheep", "Dog", "Deer", "Bison", "Elk", "Other")
Other animal with which case patient had contact with birthing products
Which animal did case patient have contact with skinning/slaughtering ("Cow", "Pig",
"Goat", "Sheep", "Dog", "Deer", "Bison", "Elk", "Other")?
If animal skinned/slaughtered is "Other", describe which animal(s) the case patient had
contact with
Which animal(s) did case patient hunt, from list "Cow", "Pig", "Goat", "Sheep", "Dog",
"Deer", "Bison", "Elk", "Other"
If type of animal hunted is "Other", specify the type(s) of animal(s) hunted
If Type of animal contact is "Other" describe the contact
If Type of animal contact is "Other", which animal did case patient have this type of
contact including "Cow", "Pig", "Goat", "Sheep", "Dog", "Deer", "Bison", "Elk", "Other"
If Type of animal contact is "Other" and animal is "Other" which animal did case
patient have this type of contact
If case patient had contact with birthing products, who owned the animal ("Case", "
Private", " Wild", " Commercial", " Unknown")
Who owned the animal which the case patient had contact with skinning/slaughter
("Case", " Private", " Wild", " Commercial", " Unknown")
Who owned the animal which the case patient had contact with hunting from list
"Case", " Private", " Wild", " Commercial", " Unknown"
If animal contact type was "Other", describe who owned the animal from this contact,
from list "Case", " Private", " Wild", " Commercial", " Unknown"

In the 6 months prior to illness onset, did the subject consume unpasteurized dairy or
undercooked meat?
If the subject consumed unpasteurized milk from which animal(s) "Cow", "Pig", "Goat",
"Sheep", "Dog", "Deer", "Bison", "Elk", "Other"
If milk animal source is "Other", describe which animal this milk product was from
Consumed fresh or soft cheese from which animal(s), including "Cow", "Pig", "Goat",
"Sheep", "Dog", "Deer", "Bison", "Elk", "Other"
If animal source of cheese is "Other", which animal(s) was the source of cheese
Consumed undercooked meat from which animal(s) "Cow", "Pig", "Goat", "Sheep",
"Dog", "Deer", "Bison", "Elk", "Other"
If animal source of meat is "Other", list the animal source(s) from which the case
patient consumed meat
If food product is "Other", describe other food consumed
If food product is "Other", select the animal sources of this food from list "Cow", "Pig",
"Goat", "Sheep", "Dog", "Deer", "Bison", "Elk", "Other"
If food product and animal are "Other", describe which animal this other food was
from
Country milk was from, "U.S.", "Other"
If milk source country is "Other", list country
If milk source country is "Other", list country
Country where the cheese product was from. Notification types include "U.S.", "Other"
If cheese source country is "Other", list country
If cheese source country is "Other", list country
Country meat was from, "U.S.", "Other"
If meat source country is "Other", list country
If meat source country is "Other", list country
Country where the food product was from. Notification types include "U.S.", "Other"
If food source country is "Other", list country
If food source country is "Other", list country
Is this case epi-linked to a laboratory-confirmed case?
Similar illness in contact of the subject?
If epi-link to a laboratory-confirmed case or similar illness in a close contact are "Yes",
then select the relationship of the contact ("Household", "Neighbor", "Co-worker",
"Other")
If Close Contact is "Other", then describe the relationship of the contact
Was the case patient exposed to Brucella, from the list "Clinical specimen", "Isolate",
"Vaccine", "Unknown"
If Brucella exposure is selected, where did exposure occur, from list "Clinical",
"Laboratory", "Farm/ranch", "Surgery", "Unknown", "Other"
If location of exposure to Brucella is "Other", specify exposure location
Exposure risk classificaiton ("high", "low", "Unknown")
If case patient was exposed to "Vaccine", choose which vaccine patient was exposed
to, from list "S19", "RB51", "Rev1", "Other"
Did the subject receive post exposure prophylaxis?

If the case-patient had a known eposure to Brucella and PEP was not taken, why not,
from list "Unaware of exposure", "Unavailable", "Allergic", "Pregnant", "Unknown",
"Other"
If no PEP taken reason was "Other", desribe the reason PEP was not taken
Did the patient complete PEP regimen ("Yes","No", "Unknown", "Partial"?
If PEP completed is "Partial", Explain why partial pep was taken
Earliest date reported to state public health system
Name of Laboratory that reported test result.
City location of Laboratory that reported test result.
State Laboratory that reported test result.
Zip code of Laboratory that reported test result.
Received from (e.g., lab name, clinician, etc)
Received from city
Received from state
Date Sample Received at Lab (accession date).
Name of agglutination test used
Acute Total antibody titer
Convalscent Total antibody titer
Based on the acute and covalscent titers for the agglutination test used, what is the
result of the paired total antibody titers (e.g., Positive, Negative, Unknown)?
Cut off value of a positive result for the Agglutination test used
Acute IgG agglutination titer
Convalscent IgG agglutination titer
Based on the acute and covalscent titers for the agglutination test used, what is the
result of the paired IgG titers (e.g., Positive, Negative, Unknown)?
Name of the ELISA test used
Acute IgG ELISA titer
Convalscent IgG ELISA titer
Based on the acute and covalscent titers for the IgG ELISA test used, what is the result
of the paired IgG titers (e.g., Positive, Negative, Unknown)?
Acute IgM ELISA titer
Convalscent IgM ELISA titer
Based on the acute and covalscent titers for the IgM ELISA test used, what is the result
of the paired IgM titers (e.g., Positive, Negative, Unknown)?
ELISA test cut off
The date the acute serum specimen was collected.
The date the convalscent serum specimen was collected.
Rose Bengal titer
Result of Rose Bengal test (e.g., Positive, Negative, Unknown)?
Cut off value of a positive result for the Rose Bengal test
Coombs Titer
Result of Coombs test (e.g., Positive, Negative, Unknown)?
Cut off value of a positive result for the Coombs test
Name of other serologic test used 1

Titer or value of other serologic test 1
Result of other serologic test 1 (e.g., Positive, Negative, Unknown)?
Cut off value of a positive result for the Other test used 1
Name of other serologic test used 2
Value of other serologic test 2
Result of other serologic test 2 (e.g., Positive, Negative, Unknown)?
Cut off value of a positive result for the Other test used 2
If PCR was done, select on which specimens it was used ("Blood", "Abscess/wound",
"Bone marrow", "CSF", "Other")
Describe the specimen if specimen tested by PCR was "Other"
The date the specimen was collected for PCR
Result of PCR (e.g., Positive, Negative, Unknown)?
What Brucella species were identified as a result of PCR ("abortus", "canis",
"melitensis", "suis", "ceti", "inopinata", "microti", "neotomae", "pinnipedalis")
If culture was done, which specimens were used ("Blood", "Abscess/wound", "Bone
marrow", "CSF", "Other")
Describe the specimen if specimen tested by culture was "Other"
The date the specimen was collected for culture
Result of culture (e.g., Positive, Negative, Unknown)?
What Brucella species were identified as a result of culture ("abortus", "canis",
"melitensis", "suis", "ceti", "inopinata", "microti", "neotomae", "pinnipedalis")
Were specimens collected before antimicrobials were taken
Was the select agent reported to CDC
Did a laboratory exposure occur during manipulation of an isolate?
If a laboratory exposure is "Yes", was it reported?
Were specimens or isolates sent to CDC for testing?
are clinical specimens or isolates still avaialble for further testing?

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

PHVS_YesNoUnknown_CDC

PHVS_State_FIPS_5-2
PHVS_County_FIPS_6-4
PHVS_AgeUnit_UCUM_NETSS
PHVS_Sex_MFU
PHVS_YesNoUnknown_CDC
PHVS_CountryofBirth_CDC
PHVS_EthnicityGroup_CDC_Unk
PHVS_RaceCategory_CDC

PHVS_CaseClassStatus_NND

PHVS_YesNoUnknown_CDC

PHVS_TemperatureUnit_UCUM
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_CountryofBirth_CDC
PHVS_CountryofBirth_CDC

PHVS_CountryofBirth_CDC
PHVS_CountryofBirth_CDC
PHVS_CountryofBirth_CDC
PHVS_CountryofBirth_CDC

PHVS_CountryofBirth_CDC
PHVS_CountryofBirth_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_State_FIPS_5-2

PHVS_State_FIPS_5-2

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

Label/Short Name
AGEMM
AGEYY
CDCNUM
CITY
COUNTY
DATECOMP
DOB
ETHNICITY
FDANUM
FNAME
LNAME
OCCUPAT
RACE
SEX
STATE
STEPINUM
STLABNUM
FEVER
NAUSEA
VOMIT
DIARRHEA
VISBLOOD
CRAMPS
HEADACHE
MUSCPAIN
CELLULIT
BULLAE
SHOCK
OTHER
MAXTEMP
CENFAR
NUMSTLS
CELLSITE
BULLSITE
OTHSPEC2
AMPMSYMP
ANTIBYN
Descant1
Descant2
Descant3
ANTNAM01
ANTNAM02
ANTNAM03

ANTNAM04
BEGANT1
BEGANT2
BEGANT3
BEGANT4
CDCISOL
DATEADMN
DATEDIED
DATEDISC
DATESYMP
DURILL
ENDANT1
ENDANT2
ENDANT3
ENDANT4
GSURGTYP
HEMOTYPE
HHSYMP
HOSPYN
IMMTYPE
LIVTYPE
MALTYPE
MISYMP
OTHCONSP
PATDIE
PEPULCER
ALCOHOL
DIABETES
INSULIN
GASSURG
HEART
HEARTFAL
HEMOTOL
IMMUNOD
LIVER
MALIGN
RENAL
RENTYPE
OTHCOND
TRTANTI
TRTCHEM
TRTRADIO
TRTSTER
TRTIMMUN
TRTACID

TRTULCER
SEQDESC
SEQUELAE
TRTACISP
TRTANTSP
TRTCHESP
TRTIMMSP
TRTRADSP
TRTSTESP
TRTULCSP
DATESPEC
SPECIESNAME
SITE
STATECON
SOURCE
OTHORGAN
SPECORGAN
AMBTEMFC
AMNTCONS
AMPMCONS
DATEAMBT
DATEFECL
DATEH2O
DATEHAR1
DATEHAR2
DATERAIN
DATESALN
DATESEAR
FECALCNT
H2OSALIN
HARVSIT1
HARVSIT2
HARVST01
HARVST02
HARVSTS1
HARVSTS2
HHCONSUM
IMPROPER
MAMTEMP
MICONSUM
RAINFALL
RESTINV
SEADISSP
SEADIST
SEAHARV

SEAIMPOR
SEAIMPSP
SEAOBT
SEAOBTSP
SEAPREP
SEAPRSP
SH2OTEMP
SH2OTMFC
SOURCES
SHIPPERS
TAGSAVA
TYPESEAF
HARVESTSTATE
HARVESTREGION
BIOTYPE
CHOLVACC
DATEVACC
ORALVACC
PAREVACC
ELISA
LATEX
RISKRAW
RISKCOOK
RISKTRAV
RISKPERS
RISKVEND
RISKOTHER
RISKSPEC
SEROTYPE
SPECTOXN
TOXGENIC
TRVOTHR
TRVPREV
TRVPREV1
TRVPREV2
TRVPREV3
TRVPREV4
TRVPREV5
TRVPREV6
TRVPREV7
TRVPREV8
TRVPREV9
TRVREAS1
TRVREAS2
TRVREAS3

TRVREAS4
TRVREAS5
TRVREAS6
TRVROTHR
AMPMEXP
HANDLING
SWIMMING
WALKING
BOATING
CONSTRN
BITTEN
ANYWLIFE
BODYH2O
CONSTRN
DATEEXPO
DATEWHI1
DATEWHI2
DATEWHI3
DATEWHO1
DATEWHO2
DATEWHO3
FISHSP
H2OCOMM
H2OTYPE
HHEXPOS
LOCEXPOS
MIEXPOS
OTHEREXP
OTHERH2O
OTHSHSP
OUTBREAK
OUTBRKSP
CLAMS
CRAB
LOBSTER
MUSS
OYSTER
SHRIMP
CRAY
OTHSH
FISH
RCLAM
RCRAB
RLOBSTER
RMUSS

ROYSTER
RSHRIMP
RCRAY
ROTHSH
RFISH
DATECLAM
DATECRAB
DATELOBS
DATEMUSS
DATEOYSTER
DATESHRI
DATECRAY
DATEOTHSH
DATEFISH
SPECEXPO
STRESID
TRAVEL
WHERE01
WHERE02
WHERE03
WOUNDEXP
WOUNDSP

Description
Age in months
Age in years
CDC Number
City
County
Date completing form
Date of birth
Hispanic or Latino origin?
FDA Number
First 3 letters of first name
First 3 letters of last name
Occupation
Race
Sex
State of exposure (usually reporting state)
State Number
State Lab Number
Fever
Nausea
Vomiting
Diarrhea
Bloody stool
Abdominal cramps
Headache
Muscle Pain
Cellulitis
Bullae
Shock
Other
Symptom: Maximum temp of fever
Fever measured in units of C or F
Symptom: # of stools/24 hours
Symptom: Site of cellulitis
Symtom: Site of Bullae
Symptom: Specify other Symptoms
Seafood Investigation: Onset in am or pm
Did patient receive antibiotics?
Name of 1st Antibiotic
Name of 2nd Antibiotic
Name of 3rd Antibiotic
Name of 1st Antibiotic (old)
Name of 2nd Antibiotic (old)
Name of 3rd Antibiotic (old)

Name of 4th Antibiotic (old)
Date began Antibiotic #1
Date began Antibiotic #2
Date began Antibiotic #3
Date began Antibiotic #4
CDC Isolate No.
Date admitted to hospital
Date of death
Date of discharge from hospital
Date of symptom onset
# days ill
Date ended Antibiotic #1
Date ended Antibiotic #2
Date ended Antibiotic #3
Date ended Antibiotic #4
Pre-existing: Type of gastric surgery
Pre-exisiting: Type of hemotological disease
Hour of symptom onset
Hospitalized?
Pre-exisiting: Type of Immunodeficiency
Pre-exisiting: type of liver disease
Pre-existing: Type of Malignancy
Minute of symptom exposure
Pre-existing: Type of Other condition
Did patient die?
Pre-existing: Peptic ulcer
Pre-existing: Alcoholism
Pre-existing: Diabetes
Pre-existing: on insulin?
Pre-existing: Gastric surgery
Pre-existing: Heart disease
Pre-existing: Heart failure?
Pre-existing: Hematologic disease
Pre-existing: Immunodeficiency
Pre-existing: Liver disease
Pre-existing: Malignancy
Pre-existing: Renal disease
Pre-existing: Type of renal disease
Pre-existing: Other
Type of treatment received: antibiotics
Type of treatment received: chemotherapy
Type of treatment received: radiotherapy
Type of treatment received: systemic steroids
Type of treatment received: immunosuppressants
Type of treatment received: antacids

Type of treatment received: H2 Blocker or other ulcer medication
Describe Sequelae
Sequelae?
If previously treated with Antacids, specifiy
If previously treated with Antibiotics, specifiy
If previously treated with chemotherapy, specifiy
If previously treated with immunosuppressants, specifiy
If previously treated with radiotherapy, specifiy
If previously treated with steroids, specifiy
If treated with ulcer meds, specifiy
Date specimen collected
Species
If other source, specify site from which Vibrio was isolated
Was Species confirmed at State PH Lab?
Specimen source
Other organism isolated from specimen?
Specify other organism isolated
Seafood Investigation: Maximum ambient temp units - F or C
Seafood Investigation: Amount of shellfish consumed
Seafood Investigation: Shellfish consumed in am or pm
Seafood investigation: Date ambient temp measured
Seafood Investigation: Date of fecal count
Seafood Investigation: Date water temp measured
Seafood Investigation: Date of harvest #1
Seafood Investigation: Date of harvest #2
Seafood Investigation: Date total rain fall recorded
Seafood Investigation: Date salinity measured
Seafood Investigation: Date restaurant rec'd seafood
Seafood Investigation: Fecal Coliform Count
Seafood Investigation: Results of Salinity test
Seafood Investigation: Harvest Site #1
Seafood Investigation: Harvest Site #2
Seafood Investigation: Status of Harvest Site #1
Seafood Investigation: Status of Harvest Site #2
Seafood Investigation: Specify if Status for Harvest Site #1 = other
Seafood Investigation: Specify if Status for Harvest Site #2 = other
Seafood Investigation: Hour of seafood consumption
Seafood Investigtaion: Improper Storage?
Seafood Investigation: Maximum ambient temp
Seafood Investigation: Minute of seafood consumption
Seafood Investigation: Total rainfall in Inches
Seafood Investigation: Investigation of Restaurant?
Seafood Investigation: Specify how shellfish distributed
Seafood Investigation: How is shellfish distributed?
Seafood Investigation: Was shellfish harvested by patient or friend?

Seafood Investigation: Was seafood imported?
Seafood Investigation: Specify country of Import
Seafood Investigation: where was seafood obtained?
Seafood Investigation: Specify from where seafood was obtained
Seafood Investigation: How was seafood prepared?
Seafood Investigation: Specify how seafood was prepared (if other)
Seafood Investigation: Surface water temperature
Surface water temp units in F or C?
Sources of seafood
Shippers who handled suspected seafood (certification numbers)
Seafood investigation: Are tags available from suspect lot?
Seafood investigation: Type of shellfish consumed
State in which seafood was harvested
Region in which seafood was harvested
Cholera Only: biotype?
Cholera Only: Patient ever received cholera vaccine
Cholera Only: Date cholera vaccine received
Cholera Only: Oral cholera vaccine received
Cholera Only: Parenteral cholera vaccine received
Cholera Only: Elisa test performed for Cholera toxin testing?
Cholera Only: Latex Agglut. performed for Cholera toxin testing?
Cholera Only: Raw seafood
Cholera Only: Cooked seafood
Cholera Only: Foreign travel
Cholera Only: Other person(s) with cholera or cholera-like illness
Cholera Only: Stree-vended food
Cholera Only: Other
Cholera Only: Other risk specified
Cholera Only: Cholera Serotype
Cholera Only: Specify other toxin test used for Cholera (if other)
Cholera Only: is it toxigenic?
Cholera prevention education: specify other source of education
Cholera prevention education prior to travel?
Cholera prevention: Pre-travel clinic
Cholera prevention: Airport
Cholera prevention: Newspaper
Cholera prevention: Friends
Cholera prevention: Private physician
Cholera prevention: Health department
Cholera prevention: Travel agency
Cholera prevention: CDC travelers' hotline
Cholera prevention: Other
Reason for travel: Visit friends/relatives
Reason for travel: Business
Reason for travel: Tourism

Reason for travel: Military
Reason for travel: Other
Reason for travel: Unknown
Cholera, reason for travel: specify if other
Seafood Investigation: Exposure to seawater in am or pm
Exposure: handing/cleaning seafood
Exposure: Swimming/diving/wading
Exposure: Walking on beach/shore/fell on rocks/shells
Exposure: Boating/skiing/surfing
Exposure: Construction/repairs
Exposure: Bitten/stung
Exposure: Contact with other marine/freshwater life
Exposure: Exposure to a body of water
Exposure to water via construction
Exposure: Date of exposure to seawater
Date traveled/entered destination #1
Date traveled/entered destination #2
Date traveled/entered destination #3
Date left/returned home #1
Date left/returned home #2
Date left/returned home #3
Type of fish
Exposure: Comments on water exposure
Exposure: Type of water exposure
Exposure: Hour of seawater exposure
Exposure: location of water exposure
Exposure: Minute of seawater exposure
Exposure: Other exposure
Exposure: Exposed to other water not listed?
Specify other shellfish consumed
Is case part of outbreak?
If part of an outbreak, Specify outbreak
Consumption: clams
Consumption: crab
Consumption: lobster
Consumption: mussels
Consumption: oysters
Consumption: shrimp
Consumption: crawfish
Consumption: other shellfish
Consumption: other fish
Raw consumption: clams
Raw consumption: crab
Raw consumption: lobster
Raw consumption: muss

Raw consumption: oyster
Raw consumption: shrimp
Raw consumption: crawfish
Raw consumption: other shellfish
Raw consumption: other fish
Date of seafood consumption: clams
Date of seafood consumption: crab
Date of seafood consumption: lobster
Date of seafood consumption: mussels
Date of seafood consumption: oysters
Date of seafood consumption: shrimp
Date of seafood consumption: crawfish
Date of seafood consumption: other shellfish
Date of seafood consumption: other fish
Specify other seawater/shellfish dripping exposure (if other)
State of residence
Exposure to travel outside home state in previous 7 days?
Travel destination #1
Travel destination #2
Travel destination #3
Did patient incur a wound before/during exposure?
If patient incurred wound before/during exposure, describe wound

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

Label/Short Name
Date of Last Evaluation by a
Healthcare Provider
Primary cause of death from death
certificate
Secondary cause of death from death
certificate
Was an autopsy performed?
Final Anatomical Diagnosis of Death
from Autopsy Report
If not a case of CRS, select reason
Gestational Age at Birth (in weeks)
Age at Diagnosis
Age (unit) at Diagnosis
Birth Weight
Birth Weight (unit)
Cataracts (Complication)
Hearing Impairment (loss)
(Complication)
Congenital Heart Disease
(Complication)
Patent Ductus Arteriosus
(Complication)
Peripheral Pulmonic Stenosis
(Complication)
Congenital Glaucoma (Complication)
Pigmentary Retinopathy
(Complication)
Developmental Delay or Mental
Retardation (Complication)
Meningoencephalitis (Complication)
Microencephaly (Complication)
Purpura (Complication)
Enlarged Spleen (Complication)
Enlarged Liver (Complication)
Radiolucent Bone Disease
(Complication)
Neonatal Jaundice (Complication)
Low Platelets (Complication)
Dermal Erythropoieses (Blueberry
Muffin Syndrome) (Complication)
Other Complication(s)
Specify Other Complication(s)

Was laboratory testing done for
Rubella on this subject?
Test Type
Test Result
Sample Analyzed Date
Test Method
Date Collected
Specimen Source
Was CRS virus genotype sequenced?
Was Rubella genotype sequenced?
Were the specimens sent to CDC for
genotyping (molecular typing)?
Specimen type sent to CDC for
genotyping
Date sent for genotyping
Type of Genotype Sequence
Did the mother have a rash?
What was the mother's rash onset
date?
Mother's Rash Duration (in days)
Did the mother have a fever?
What was the mother's fever onset
date?
Mother's Fever Duration (in days)
Did the mother have
arthralgia/arthritis?
Did the mother have
lymphadenopathy?
Other clinical features of maternal
illness
Mother's birth country
Length of time mother has been in
the US
Mother's age at delivery
Mother's occupation at time of
conception
Did the mother attend a family
planning clinic prior to conception of
this infant?
Number of children less than 18
years of age living in household
during this pregnancy?
Were any of the children living in the
household immunized with Rubellacontaining vaccine?

Number of children less than 18
years of age immunized with the
rubella vaccine
Was prenatal care obtained for this
pregnancy?
Date of first prenatal visit for this
pregnancy
Where was prenatal care for this
pregnancy obtained?
Did the mother have serological
testing prior to this pregnancy?
Was there a rubella-like illness during
this pregnancy?
Month of pregnancy in which
symptoms first occurred
Rubella Lab Testing Mother
Was Rubella diagnosed by a
physician at time of illness?
If Rubella was not diagnosed by a
physician, diagnosed by whom?
Was Rubella serologically confirmed
at time of illness?
Serologically Confirmed Date
Serologically Confirmed Result
Mother Reported Rubella Case
Does the mother know where she
might have been exposed to Rubella?
If location of exposure is unknown,
did the mother travel outside the US
during the first trimester of
pregnancy
International Destination(s) of recent
travel
Date left for travel
Date returned from travel
Was the mother directly exposed to a
confirmed case?
If mother directly exposed to a
confirmed Rubella case, specify the
relationship
Mother's date of exposure to a
confirmed rubella case
Has mother given birth in the US
previously?
If mother has given birth in US, list
dates (years)

Number of previous pregnancies
Number of live births (total)
If mother has given birth in US,
number of births delivered in U.S.
Mother immunized with rubellacontaining vaccine?
Source of mother's Rubellacontaining vaccine information
Source of mother's rubellacontaining vaccine
Vaccine Administered
Vaccine Manufacturer
Vaccine Lot Number
Vaccine Administered Date
US Acquired

Description
The date the patient was last evaluated by a healthcare provider
The primary cause of subject's death, as noted on the death certificate
The secondary cause of subject's death, as noted on the death certificate.
Was an autopsy performed on the subject's body?
The final anatomical cause of subject's death
The reason this was not a case of CRS.
The subject's gestational age (in weeks) at birth
The subject's age at the time of diagnosis.
The age units at the time of diagnosis
The subject's birth weight
The subject's birth weight units
Did/does the subject have cataracts?
Did/does the subject have hearing impairment (loss)?
Did the subject have a congenital heart disease?
Did/does the subject have patent ductus arteriosus?
Did/does the subject have peripheral pulmonic stenosis?
Did/does the subject have congenital glaucoma?
Did/does the subject have pigmentary retinopathy?
Did/does the subject have developmental delay or mental retardation?
Did the subject have meningoencephalitis?
Did the subject have microencephaly?
Did the subject have purpura?
Did/does the subject have an enlarged spleen?
Did/does the subject have an enlarged liver?
Did the subject have radiolucent bone disease?
Did the subject have jaundice?
Did/does the subject have low platelets?
Did subject have dermal erythropoisesis?
Did the subject develop other conditions as a complication of this illness?
Please specify the other complication(s) the subject developed, during or as a result of
this illness.

Was laboratory testing done for Rubella on this subject?
Epidemiologic interpretation of the type of test(s) performed for this case
Epidemiologic interpretation of the results of the tests performed for this case
The date the lab test was performed
The technique or method used to perform the test and obtain the test results.
Date of specimen collection
The medium from which the specimen originated.
Identifies whether the CRS virus was genotype sequenced
Identifies whether the Rubella virus was genotype sequenced
Were clinical specimens sent to CDC laboratories for genotyping (molecular typing)?
Specimen type sent to CDC for genotyping
The date the specimens were sent to the CDC laboratories for genotyping.
Identifies the genotype sequence of the Rubella virus
Did the mother have a maculopapular rash?
What was the mother's rash onset date?
How many days did the mother's rash being reported in this investigation last?
Did the mother have a fever?
What was the mother's rash onset date?
How many days did the mother's rash being reported in this investigation last?
Did the mother have arthralgia/arthritis?
Did the mother have lymphadenopathy?
Mother's other clinical features of maternal illness
The mother's country of birth
Length of time (in years) the mother has been in the U.S.
The age of the mother when the infant (subject) was delivered
The mother's occupation at time of this conception
Did the mother attend a family planning clinic prior to conception of this infant?

The number of the mother's children less then 18 years of age living in household
during this pregnancy
Were any of the mother's children less than 18 years of age immunized with the
rubella vaccine?

The number of the mother's children less than 18 years of age immunized with the
rubella vaccine
Was prenatal care obtained for this pregnancy?
Date of the first prenatal visit for this pregnancy
Where was the prenatal care for this pregnancy obtained?
Did the mother have serological testing prior to this pregnancy?
Was there a rubella-like illness during this pregnancy?
The month of pregnancy that Rubella-like symptoms appeared
Was Rubella lab testing performed for the mother in conjunction with this pregnancy?
Was the mother diagnosed with Rubella by a physician at time of illness?
If the mother was not diagnosed with Rubella by a physician, then diagnosed by
whom?
Was Rubella serologically confirmed (mother) at time of illness?
The date Rubella was serologically confirmed (mother)
The result of the Rubella serological confirmation (mother)
Has the mother ever been reported as a Rubella case?
Did the mother know where she might have been exposed to Rubella?

If the Rubella exposure is unknown, did the mother travel outside the US during the
first(1st) trimester of pregnancy?

List any international destinations of recent travel
The date the mother left for all international travel
The date the mother returned to United States from travel
Was the mother directly exposed to a confirmed Rubella case?
The mother's relationship to the confirmed Rubella case

The mother's exposure date to the confirmed rubella case
Has mother given birth in the US previously?
List years in which mother has given birth in US previously

Mother's number of previous pregnancies
Mother's total number of live births
Mother's number of births delivered in U.S.
Was the mother immunized with Rubella vaccine?
Source of mother's Rubella immunization information
Source of mother's Rubella vaccine
The type of vaccine administered, (e.g., Varivax, MMRV). First question of a repeating
group of vaccine questions.
Manufacturer of the vaccine. Second question of a repeating group of vaccine
questions.
The vaccine lot number of the vaccine administered. Third question of a repeating
group of vaccine questions.
The date that the vaccine was administered. Fourth question of a repeating group of
vaccine questions.
Sub-classification of disease or condition acquired in the US

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

PHVS_YesNoUnknown_CDC

PHVS_NoCaseReason_CRS

PHVS_AgeUnit_UCUM
PHVS_WeightUnit_UCUM
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_LabTestProcedure_Rubella
PHVS_LabTestInterpretation_VPD
PHVS_LabTestMethod_CDC
PHVS_SpecimenSource_VPD
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_SpecimenSource_VPD

PHVS_Genotype_Rubella
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_Country_ISO_3166-1

PHVS_Occupation_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_PrenatalCareProvider_Rubella
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_LabTestInterpretation_VPD
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_Country_ISO_3166-1

PHVS_YesNoUnknown_CDC
PHVS_Relationship_VPD

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_ImmunizationInformationSource_CRS
PHVS_PrenatalCareProvider_Rubella
PHVS_VaccinesAdministeredCVX_CDC_NIP
PHVS_ManufacturersOfVaccinesMVX_CDC_NIP

PHVS_CaseClassificationExposureSource_NND

Label/Short Name
RECTYPE

Description
Record type will determine how the
record is handled when it arrives at CDC.

UPDATE
STATE

Currently not implemented.
Reporting State FIPS code - (e.g., "06",
"13").
MMWR Year (2-digits) for which case
information reported to CDC.
Unique Case ID (numeric only) assigned by
the state.
Location code used by the state to indicate
where report originated and who has
responsibility for maintaining the record.
(NOTE: STD*MIS software substitutes a '#'
for the leading 'S' in codes listed).

YEAR
CASEID
SITE

WEEK

EVENT
COUNT
COUNTY
BIRTHDATE
AGE
AGETYPE

MMWR Week on Surveillance Calendar,
i.e., week for which case information
reported to CDC.
Event (disease) code for the disease being
reported.
For case records this field will always
contain "00001".
FIPS code for reporting county
(999=Unknown)
Date of birth of infant in YYYYMMDD
format (99999999=Unknown)
Estimated Gestational Age in weeks - (e.g.,
"038", "042") (999= Unknown)
Indicates the units (weeks) for the AGE
field.

RACE

Race of Mother.

HISPANIC

Indicator for Mother's Hispanic ethnicity.

EVENTDATE

Date of Report to Health Department in
YYMMDD format
A code describing the type of date
provided in EVENTDATE.
Recode of Case Classification.

DATETYPE
CASE STATUS

OUTBREAK

Indicates whether the case was associated
with an outbreak.

INFOSRCE

Information Source/Provider Codes (from
Interview Record if available).

DETECTED

Method of Case Detection (from Interview
Record if available).

MZIP
MSTATE

Zip Code for Mother's Residence
FIPS Code for Mother's State of Residence.
Code 98 for Mexico and 97 for any other
non-USA residence. (999=Unknown)

MCOUNTY

FIPS Code for Mother's County of
Residence. Code 998 for Mexico and 997
for any other non-USA residence.
(999=Unknown)
Mother's Date of Birth in YYYYMMDD
format. (99999999=Unknown)
Mother's Marital Status.

MBIRTH
MARITAL

LMP

PRENATAL

Date of Mother's Last Menstrual Period
before delivery in YYYYMMDD format.
(99999999=Unknown)
Did mother have prenatal care?

PNCDATE1

Date of mother's first prenatal visit in
YYYYMMDD format. (99999999=Unknown)

DATEA

Date of mother’s most recent nontreponemal test in YYYYMMDD format.
(99999999=Unknown)
Result of mother’s most recent nontreponemal test.

RESULTA

DATEB

RESULTB

TITER

VITAL

Date of mother’s first non-treponemal test
in YYYYMMDD format.
(99999999=Unknown)
Result of mother’s first non-treponemal
test.

Titer of mother’s most recent nontreponemal test. (The titer for date b is in
columns 214-217).
Vital status of infant/child.

DEATHDAT

Date of death of infant/child in
YYYYMMDD format.

BIRTHWT
REACSTS

Birthweight in grams (9999=Unknown)
Did infant/child have reactive nontreponemal test for syphilis?

REACDATE

Date of infant/child's first reactive nontreponemal test for syphilis in YYYYMMDD
format. (99999999=Unknown)

DARKFLD

Did the infant/child, placenta, or cord have
darkfield exam, DFA, or special stains?

XRAYS

Did infant/child have long bone x-rays?

CSFVDRL

Did infant/child have a CSF-VDRL?

TREATED

Was infant/child treated?

CLASS

Case Classification.

ID126

CDC 73.126 form Case ID number
(9999999=Unknown)
CDC 73.126 Form Version.
Titer of mother’s first non-treponemal test
b.

VERSION
TITERB

INFTITER

Titer of infant/child’s first reactive nontreponemal test for syphilis.

AMIND
ASIAN

American Indian/Alaskan Native:
Asian:

BLACK
WHITE
NAHAW

Black:
White:
Native Hawaiian or Other Pacific Islander:

RACEOTH
RACEUNK
MCOUNTRY

Other Race:
Unknown Race:
Mother’s country of residence.
(XX=Unknown)
Did infant/child have reactive treponemal
test?

REACTREP

RTDATE

STD IMPORT

GRAVIDA
PARA
PNCTRI

Date of infant/child’s reactive treponemal
test in YYYYMMDD format.
(99999999=Unknown)
Was case imported? Was disease acquired
elsewhere? Indicates probable location of
disease acquisition relative to reporting
state values.

Number of pregnancies (e.g. 01)
(99=Unknown)
Number of live births (e.g. 03)
(99=Unknown)
Trimester of mother’s first prenatal visit.

TESTVISA

Did mother have non-treponemal or
treponemal test at first prenatal visit?

TESTVISB

Did mother have non-treponemal or
treponemal test at 28-32 weeks gestation?

TESTVISC

Did mother have non-treponemal or
treponemal test at delivery?

TREPDTA

Date of mother’s first treponemal test in
YYYYMMDD format. (99999999=Unknown)

TESTTYPA

Test type of mother’s first treponemal
test.

TREPRESA

Result of mother’s first treponemal test.

TREPDTB

Date of mother’s most recent treponemal
test in YYYYMMDD format.
(99999999=Unknown)
Test type of mother’s most recent
treponemal test.

TESTTYPB

TREPRESB

Result of mother’s most recent
treponemal test.

HIVSTAT

What was mother’s HIV status during
pregnancy?

CLINSTAG

What clinical stage of syphilis did mother
have during pregnancy?

SURVSTAG

What surveillance stage of syphilis did
mother have during pregnancy?

FIRSTDT

Date of mother’s first dose of benzathine
penicillin in YYYYMMDD format.
(99999999=Unknown)

FIRSTDOS

When did mother receive her first dose of
benzathine penicillin?

MOMTX

What was mother’s treatment?

RESPAPP2

Did mother have an appropriate serologic
response?

CLINNO
CLINLATA
CLINSNUF
CLINRASH
CLINHEPA
CLINJUAN
CLINPARA
CLINEDEM
CLINOTH
CLINUNK
CSFWBC

No signs/asymptomatic?
Condyloma lata?
Snuffles?
Syphilitic skin rash?
Hepatosplenomegaly?
Jaundice/Hepatitis?
Pseudo paralysis?
Edema?
Other signs of CS?
Unknown signs of CS?
Did the infant/child have a CSF WBC count
or CSF protein test?

Value Set Code. Search in PHIN VADS using the following link (https://phinvads.cdc.gov/vads/SearchHome.action)
Value for case data: M=MMWR report

(Pad with a 9)

S01=State epidemiologist
S02=State STD Program
S03=State Chronic Disease Program
S04-S99=Other state offices
R01-R99=Regional or district offices
001-999=County health depts (FIPS codes)
L01-L99=Laboratories within state
CD1=Historical records (prior to new format)
CD2=Entered at CDC (based on phone reports)

10316=Syphilis (congenital)

2=0-52 Weeks
9=Gestational Age Unknown (AGE field should be
999)

1=American Indian/Alaskan Native
2=Asian or Pacific Islander
3=Black
5=White
8=Other
9=Unknown
NOTE: Please use only one of the codes above if a
single race was selected. If multiple races were
selected, enter code 8=Other for Race and also
select the appropriate race categories that apply in
columns 238-244.
1=Hispanic/Latino
2=Non-Hispanic/Latino
9=Unknown

4=Date of first report to community health system
1=Confirmed, Probable, or Syphilitic stillbirth
2=Not a case
9=Unknown
1=Yes
2=No
9=Unknown

01=HIV Counseling and Testing Site
02=STD clinic
03=Drug Treatment
04=Family Planning
06=Tuberculosis clinic
07=Other Health Department clinic
08=Private Physician/HMO
10=Hospital-Emergency Room; Urgent Care Facility
11=Correctional Facility
12=Laboratory
13=Blood Bank
14=Labor and Delivery
15=Prenatal
16=National Job Training Program
17=School-based Clinic
18=Mental Health Provider
29=Hospital-Other
66=Indian Health Service
77=Military
88=Other
99=Unknown (if data not available)
20=Screening
21=Self-referred
22=Patient referred partner
23=Health Department referred partner
24= Cluster related
88=Other
99=Unknown
99999=Unknown (if data not available)

1=Single, never married
2=Married
3=Separated/Divorced
4=Widow
8=Other
9=Unknown

0=No prenatal care
9=Unknown

1=Reactive
2=Nonreactive
9=Unknown

1=Reactive
2=Nonreactive
9=Unknown
0=weakly reactive
9999=Unknown
1=Alive
2=Born alive, then died
3=Stillborn
9=Unknown
(If alive, pad with 99999999)
(99999999=Unknown)

1=Yes
2=No
3=No test
9=Unknown

1=Yes, positive
2=Yes, negative
3=No test
4=No lesions and no tissue to test
9=Unknown
1=Yes, changes consistent with CS
2=Yes, no signs of CS
3=No x-rays
9=Unknown
1= Yes, reactive
2=Yes, nonreactive
3=No test
9=unknown
1=Yes, with Aqueous or Procaine Penicillin for 10
days
3=Yes, with Benzathine penicillin x 1
4=Yes, with other treatment
5=No treatment
9=Unknown
1=Not a case
2=Confirmed Case (laboratory confirmed
identification of T.pallidum, e.g., darkfield or direct
fluorescent antibody positive lesions)
3=Syphilitic stillbirth
4=Probable case (a case identified by the algorithm,
which is not a confirmed case or syphilitic stillbirth)

41306
0=weakly reactive
9999=Unknown
Note: All entries should be left justified (no
preceding or trailing zeroes). Example: If titer is
1:64, enter 64; if titer is 1:1024, enter 1024.
0=weakly reactive
9999=Unknown
Note: All entries should be left justified (no
preceding or trailing zeroes). Example: If titer is
1:64, enter 64; if titer is 1:1024, enter 1024.
If mother multi-racial: 1 = Yes; 2 = No; Otherwise pad with a 9.
If mother multi-racial: 1 = Yes; 2 = No; Otherwise pad with a 9.

If mother multi-racial: 1 = Yes; 2 = No; Otherwise pad with a 9.
If mother multi-racial: 1 = Yes; 2 = No; Otherwise pad with a 9.
If mother multi-racial: 1 = Yes; 2 = No; Otherwise pad with a 9.
If mother multi-racial: 1 = Yes; 2 = No; Otherwise pad with a 9.
If mother multi-racial: 1 = Yes; 2 = No; Otherwise pad with a 9.

1 = Yes
2 = No
3 = No test
9 = Unknown

N = Not an imported case
C = Yes, imported from another country
S = Yes, imported from another state
J = Yes, imported from another county/jurisdiction
in the state
D = Yes, imported but not able to determine source
state and/or country
U = Unknown

1 = 1st trimester
2 = 2nd trimester
3 = 3rd trimester
9 = Unknown
1 = Yes
2 = No
9 = Unknown
1 = Yes
2 = No
9 = Unknown
1 = Yes
2 = No
9 = Unknown

1 = EIA or CLIA
2 = TP-PA
3 = Other
9 = Unknown
1 = Reactive
2 = Nonreactive
9 = Unknown

1 = EIA or CLIA
2 = TP-PA
3 = Other
9 = Unknown
1 = Reactive
2 = Nonreactive
9 = Unknown
P = Positive
E = Equivocal test
X = Patient not tested
N = Negative
U = Unknown
1 =Primary
2 = Secondary
3 = Early latent
4 = Late or late latent
5 = Previously treated/serofast
8 = Other
9 = Unknown
1 = Primary
2 = Secondary
3 = Early latent
4 = Late or late latent
8 = Other
9 = Unknown

1 = Before pregnancy
2 = 1st trimester
3 = 2nd trimester
4 = 3rd trimester
5 = No Treatment
9 = Unknown
1 = 2.4 M units benzathine penicillin
2 = 4.8 M units benzathine penicillin
3 = 7.2 M units benzathine penicillin
8 = Other
9 = Unknown
1 = Yes, appropriate response
2 = No, inappropriate response: evidence of
treatment failure or reinfection
3 = Response could not be determined from
available non-treponemal titer information
4 = Not enough time for titer to change
1 = Yes; Otherwise pad with a 9.
1 = Yes; Otherwise pad with a 9.
1 = Yes; Otherwise pad with a 9.
1 = Yes; Otherwise pad with a 9.
1 = Yes; Otherwise pad with a 9.
1 = Yes; Otherwise pad with a 9.
1 = Yes; Otherwise pad with a 9.
1 = Yes; Otherwise pad with a 9.
1 = Yes; Otherwise pad with a 9.
1 = Yes; Otherwise pad with a 9.
1 = Yes, CSF WBC count elevated
2 = Yes, CSF protein elevated
3 = Both tests elevated
4 = Neither test elevated
5 = No test
9 = Unknown

chHome.action)

Label/Short Name
Animal Contact Questions Indicator
Animal Contact Indicator
Animal Type Code(s)
Animal Type Other
Amphibian Other
Reptile Other
Mammal Other
Animal Contact Location
Acquired New Pet
Applicable Incubation Period
Associated with Daycare Indicator
Day Care Attendee
Day Care Worker
Live with Day Care Attendee
Day Care Type
Day Care Facility Name
Food Prepared at this Daycare
Diapered Infants at this Daycare
Drinking Water Exposure Indicator
Home Tap Water Source Code
Home Well Treatment Code
Home Tap Water Source Other
School/Work Tap Water Source Code
SchoolWork Well Treatment Code
School/Work Tap Water Source
Other
Drink Untreated Water 14 days Prior
to Onset
Food Handler
Food Handler after Illness Onset
Food HandlerLast Worked Date
Food Handler Location
Recreational Water Exposure
Questions Indicator
Recreational Water Exposure 14 Days
Prior to Onset
Recreational Water Exposure Type
Code(s)
Recreational Water Exposure Type
Other
Swimming Pool Type Code(s)
Swimming Pool Type Other
Recreational Water Location Name

Related Case Indicator
Patient Knows of Similarly Ill Persons
Health Department Investigated
Other Related Cases
Travel Questions Indicator
Travel Prior To Onset
Incubation Period
Travel Purpose Code(s)
Travel Purpose Other
Destination 1 Type:
(Domestic) Destination 1:
(International) Destination 1
Mode of Travel: (1)
Date Of Arrival (1)
Date of Departure (1)
Destination 2 Type
(Domestic) Destination 2
(International) Destination 2
Mode of Travel: (2)
Date of Arrival: (2)
Date of Departure (2)
Destination 3 Type:
(Domestic) Destination 3:
(International) Destination 3
Mode of Travel: (3)
Date of Arrival: (3)
Date of Departure (3)
Other Destination Txt
Reporting Lab Name
Reporting Lab CLIA Number
Local record ID (case ID)

Filler Order Number
Ordered Test Name

Date of Specimen Collection
Specimen Site
Specimen Number

Specimen Source
Specimen Details
Date Sample Received at Lab
Sample Analyzed date
Lab Report Date
Report Status
Resulted Test Name
Numeric Result
Result Units
Coded Result Value
Organism Name
Lab Result Text Value
Result Status
Interpretation Flag

Reference Range From
Reference Range To
Test Method
Lab Result Comments

Date received in state public health
lab
Lab Test Coded Comments
Genotyping/ Subtyping
Genotyping Sent Date
Genotype/Subtype location
Genotype
Subtype
Track Isolate
Patient status at specimen collection
Isolate received in state public health
lab
Reason isolate not received
Reason isolate not received (Other)
Date received in state public health
lab
State public health lab isolate id
number

Case confirmed at state public health
lab
AgClinic
AgClinicTestType
AgeMnth
AgeYr
AgSphl
AgSphlTestType
BloodyDiarr
Diarrhea
DtAdmit2
DtDisch2
DtEntered
DtRcvd
DtRptComp
DtSpec
DtUSDepart
DtUSReturn
EforsNum
Fever
HospTrans
Immigrate
Interview
LabName
LocalID
OtherCdcTest
OtherClinicTest
OtherClinicTestType
OtherSphlTest
OtherSphlTestType
OutbrkType
PatID
PcrCdc
PcrClinic
PcrClinicTestType
PcrSphl

PersonID

ResultID
RptComp
SentCDC
SLabsID
SpeciesClinic
SpeciesSphl
SpecSite
StLabRcvd

TravelDest
TravelInt

Description
If contact with animal, then display the following questions
Did patient come in contact with an animal?
Type of animal: (MULTISELECT)
If “Other,” please specify other type of animal:
If “Other Amphibian,” please specify other type of amphibian:
If “Other Reptile,” please specify other type of reptile:
If "Other Mammal," please specify other type of mammal:
Name or Location of Animal Contact:
Did the patient acquire a pet prior to onset of illness?
Applicable incubation period for this illness is
If Patient associated with a day care center:
Attend a day care center?
Work at a day care center?
Live with a day care center attendee?
What type of day care facility?
What is the name of the day care facility?
Is food prepared at this facility?
Does this facility care for diapered persons?
If patient has had Drinking Water exposure, then display the following questions
What is the source of tap water at home?
If “Private Well,” how was the well water treated at home?
If “Other,” specify other source of tap water at home:
What is the source of tap water at school/work?
If “Private Well,” how was the well water treated at school/work?
If “Other,” specify other source of tap water at school/work:
Did patient drink untreated water 14 days prior to onset of illness?
If patient is a Food Handler, then display the following questions
Did patient work as a food handler after onset of illness?
What was the last date worked as a food handler after onset of illness?
Where was patient a food handler?
If patient has had recreational water exposure, then display the following
Was there recreational water exposure in the 14 days prior to illness?
What was the recreational water exposure type? (MULTISELECT)
If "Other," please specify other recreational water exposure type:
If "Swimming Pool," please specify swimming pool type: (MULTISELECT)
If "Other," please specify other swimming pool type:
Name or location of water exposure:

If related cases are associated to this case, then display the following questions
Does the patient know of any similarly ill persons?
If "Yes," did the health department collect contact information about other similarly ill
persons and investigate further?
Are there other cases related to this one?
If patient has traveled, then display the following questions
Did the patient travel prior to onset of illness?
Applicable incubation period for this illness is 14 days
What was the purpose of the travel? (MULTISELECT)
If “Other,” please specify other purpose of travel:
Destination 1 Type:
(Domestic) Destination 1:
(International) Destination 1
Mode of Travel: (1)
Date of Arrival: (1)
Date of Departure (1)
Destination 2 Type
(Domestic) Destination 2
(International) Destination 2
Mode of Travel: (2)
Date of Arrival: (2)
Date of Departure (2)
Destination 3 Type:
(Domestic) Destination 3:
(International) Destination 3
Mode of Travel: (3)
Date of Arrival: (3)
Date of Departure (3)
If more than 3 destinations, specify details here:
Name of Laboratory that reported test result.
CLIA (Clinical Laboratory Improvement Act) identifier for the laboratory that performed
the test.
Sending system-assigned local ID of the case investigation with which the subject is
associated. This field has been added to provide the mapping to the case/investigation
to which this lab result is associated. This field should appear exactly as it ap
A laboratory generated number that identifies the test/order instance.
Ordered Test Name is the lab test ordered by the physician. It will always be included
in an ELR, but there are many instances in which the user entering manual reports will
not have access to this information.
The date the specimen was collected.
This indicates the physical location, of the subject, where the specimen originated.
Examples include: Right Internal Jugular, Left Arm, Buttock, Right Eye, etc.
A laboratory generated number that identifies the specimen related to this test.

The medium from which the specimen originated. Examples include whole blood,
saliva, urine, etc.
Specimen details if specimen information entered as text.
Date Sample Received at Lab (accession date).
The date and time the sample was analyzed by the laboratory.
Date result sent from Reporting Laboratory.
The status of the lab report.
The lab test that was run on the specimen.
Results expressed as numeric value/quantitative result.
The unit of measure for numeric result value.
Coded qualitative result value.
The organism name as a test result. This element is used when the result was reported
as an organism.
Textual result value, used if result is neither numeric nor coded.
The Result Status is the degree of completion of the lab test.
The interpretation flag identifies a result that is not typical as well as how it's not
typical. Examples: Susceptible, Resistant, Normal, Above upper panic limits, below
absolute low.
The reference range from value allows the user to enter the value on one end of a
expected range of results for the test. This is used mostly for quantitative results.
The reference range to value allows the user to enter the value on the other end of a
valid range of results for the test. This is used mostly for quantitative results.
The technique or method used to perform the test and obtain the test results.
Examples: Serum Neutralization, Titration, dipstick, test strip, anaerobic culture.
Comments having to do specifically with the lab result test. These are the comments
from the NTE segment if the result was originally an Electronic Laboratory Report.
Date the isolate was received in state public health laboratory.
Explanation for missing result (e.g., clotting, quantity not sufficient, etc.)
Indicate whether the specimens were genotyped and/or subtyped
If the specimen was sent to the CDC for genotyping, date on which the specimens were
sent.
Indicate where Genotype and/or subtype testing was performed
If the specimen was sent for genotype identification, indicate the genotype
If the specimen was sent for subtype idenfication, indicate the subtype
Track Isolate functionality indicator
Patient status at specimen collection
Isolate received in state public health lab
Reason isolate not received
Reason isolate not received (Other)
Date received in state public health lab
State public health lab isolate id number

Case confirmed at state public health lab
What was the result of specimen testing using an antigen-based test (e.g. EIA or lateral
flow) at a clinical laboratory?
Name of antigen-based test used at clinical laboratory
Age of case-patient in months if patient is <1yr
Age of case-patient in years
What was the result of specimen testing using an antigen-based test (e.g. EIA or lateral
flow) at a state public health laboratory?
Name of antigen-based test used at state public health laboratory
Did the case-patient have bloody diarrhea (self reported) during this illness?
Did the case-patient have diarrhea (self-reported) during this illness?
Date of hospital admission for second hospitalization for this illness
Date of hospital discharge for second hospitalization for this illness
Date case was entered into site's database
Date case-pateint's specimen was received in laboratory for initial testing
Date case report form was completed
Case-patient's specimen collection date
If case-patient patient traveled internationally, date of departure from the U.S.
If case-patient traveled internationally, date of return to the U.S.
CDC FDOSS outbreak ID number
Did the case-patient have fever (self-reported) during this illness?
If case-patient was hospitalized, was s/he transferred to another hospital?
Did case-patient immigrate to the U.S.? (within 15 days of illness onset)
Was the case-patient interviewed by public health (i.e. state or local health
department) ?
Name of submitting laboratory
Case-patient's medical record number
What was the result of specimen testing using another test at CDC?
What was the result of specimen testing using another test at a clinical laboratory?
Name of other test used at a clinical laboratory
What was the result of specimen testing using another test at a state public health
laboratory?
Name of other test used at a state public health laboratory
Type of outbreak that the case-patient was part of
Case-patient identification number
What was the result of specimen testing for diagnosis using PCR at CDC? (Do not enter
PCR results if PCR was performed for speciation or subtyping).
What was the result of specimen testing using PCR at a clinical laboratory? (where goal
of testing is primary detection not subtyping or speciation)
Name of PCR assay used
What was the result of specimen testing for diagnosis using PCR at the state public
health laboratory? (Do not enter PCR results if PCR was performed for speciation or
subtyping).
Unique identification number for person or patient

Unique identifier for laboratory result
Is all of the information for this case complete?
Was specimen or isolate forwarded to CDC for testing or confirmation?
State lab identification number
What was the species result at clinical lab?
What was the species result at SPHL?
Case patient's specimen collection source
Was the isolate sent to a state public health laboratory? (Answer 'Yes' if it was sent to
any state lab, even if it was sent to a lab outside of the case's state of residence)
If case-patient traveled internationally, to where did they travel?
Did the case patient travel internationally? (within 15 days of onset)

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
Yes No Indicator (HL7)
Yes No Unknown (YNU)
Animal Type (FDD)

Yes No Unknown (YNU)
Yes No Indicator (HL7)
Yes No Unknown (YNU)
Yes No Unknown (YNU)
Yes No Unknown (YNU)
Day CareType (FDD)
Yes No Unknown (YNU)
Yes No Unknown (YNU)
Yes No Indicator (HL7)
Tap Water Source (FDD)
Well Water Treatment (FDD)
Tap Water Source (FDD)
Well Water Treatment (FDD)

Yes No Unknown (YNU)
Yes No Indicator (HL7)
Yes No Unknown (YNU)

Yes No Indicator (HL7)
Yes No Unknown (YNU)
Recreational Water (FDD)

Swimming Pool Type (FDD)

Yes No Indicator (HL7)
Yes No Unknown (YNU)
Yes No Unknown (YNU)
Other Related Cases
Yes No Indicator (HL7)
Yes No Unknown (YNU)
Travel Purpose
Travel Destination Type
State
Country
Travel Mode

Travel Destination Type
State
Country
Travel Mode

Travel Destination Type
State
Country
Travel Mode

Ordered Test

Specimen

Specimen

Result Status (HL7)
Lab Test Result Name (FDD)
Units Of Measure
Lab Test Result Qualitative
Microorganism (FDD)

Observation Result Status (HL7)
Abnormal Flag (HL7)

Observation Method

Missing Lab Result Reason
Yes No Unknown (YNU)

Yes No Indicator (HL7)
Patient Location Status at Specimen Collection
Yes No Unknown (YNU)
Isolate Not Received Reason

Yes No Unknown (YNU)

Label/Short Name
Cabbage
Interview Status
Travel Destination Type
Travel Mode
Travel Purpose
Date of departure
Date of arrival
Destination code
Destination description
Person Knows of Similarly Ill Persons
Diarrhea Indicator
Max Stools per 24 Hrs
Weight Loss
Baseline Weight
Baseline Weight Units
Weight Lost
Weight Lost Units
Fever
Temperature
Temperature Units
Cyclosporiasis Symptom Code(s)
Cyclosporiasis Symptoms Other
Cyclosporiasis Confirmed By CDC
Treated For Cyclosporiasis
Sulfa Allergy
Fresh Berries Code(s)
Fresh Berries Other
Fresh Herbs Code(s)
Fresh Herbs Other
Lettuce Last 14 Days Code(s)
Lettuce Last 14 Days Other
Produce Last 14 Days Code(s)
Produce Last 14 Days Other
Fruit Other Than Berries Specify
Attend Events 14 Days Prior to Onset
Event Specify
Event Date

Eat at Restaurant 14 Days Prior to
Onset
Restaurant(s) Specify
Reporting Lab Name
Reporting Lab CLIA Number
Local record ID (case ID)

Filler Order Number
Ordered Test Name

Date of Specimen Collection
Specimen Site
Specimen Number
Specimen Source
Specimen Details
Date Sample Received at Lab
Sample Analyzed date
Lab Report Date
Report Status
Resulted Test Name
Numeric Result
Result Units
Coded Result Value
Organism Name
Lab Result Text Value
Result Status
Interpretation Flag

Reference Range From
Reference Range To
Test Method
Lab Result Comments

Date received in state public health
lab

Lab Test Coded Comments
Sent to CDC for Genotyping
Genotyping Sent Date
Sent For Strain ID
Strain Type
Track Isolate
Patient status at specimen collection
Isolate received in state public health
lab
Reason isolate not received
Reason isolate not received (Other)
Date received in state public health
lab
State public health lab isolate id
number
Case confirmed at state public health
lab
AgClinic
AgClinicTestType
AgeMnth
AgeYr
AgSphl

AgSphlTestType
BloodyDiarr
Diarrhea
DtAdmit2
DtDisch2
DtEntered
DtRcvd
DtRptComp
DtSpec
DtUSDepart
DtUSReturn
EforsNum
Fever
HospTrans
Immigrate
Interview
LabName
LocalID

OtherCdcTest
OtherClinicTest
OtherClinicTestType
OtherSphlTest
OtherSphlTestType
OutbrkType
PatID
PcrCdc
PcrClinic
PcrClinicTestType
PcrSphl

PersonID
ResultID
RptComp
SentCDC
SLabsID
SpecSite
StLabRcvd

TravelDest
TravelInt

Description
Was fresh cabbage consumed in the 14 days prior to onset of illness?
Interview Status
Travel Destination Type
Travel Mode
Purpose of Travel
Departure Date
Arrival Date
FIPS code assigned to city/state/country
Name of city/state/country
Does the patient know of any similarly ill persons?
Did the patient have diarrhea?
If "Yes,” please specify maximum number of stools per 24 hours:
Did patient experience weight loss?
If “Yes,” please specify baseline weight:
specify baseline weight in lbs or kgs
Specify how much weight was lost:
Specify weight loss in lbs or kgs
Did patient have a fever?
If "Yes," please specify temperature (observation includes units)
Specify temperature in fahrenheit or centigrade
Did the patient have any of the following signs or symptoms of Cyclosporiasis?
(MULTISELECT)
If “Other,” please specify other signs or symptoms of Cyclosporiasis:
Was the case confirmed at the CDC lab?
Was the patient treated for Cyclosporiasis?
Does the patient have a sulfa allergy?
What fresh berries were eaten in the 14 days prior to onset of illness? (MULTISELECT)
If “Other,” please specify other type of fresh berries:
What fresh herbs were eaten in the 14 days prior to onset of illness? (MULTISELECT)
If “Other,” please specify other type of fresh herbs:
What fresh lettuce was eaten in the 14 days prior to onset of illness? (MULTISELECT)
If “Other,” please specify other type of fresh lettuce:
What other types of fresh produce were eaten in the 14 days prior to onset of illness?
(MULTISELECT)
If “Other,” please specify other type of fresh produce:
If "Fruit, other than berries," please specify type of fruit other than berries:
Did patient attend any events in the 14 days prior to onset of illness?
If “Yes,” please specify the event:
Date of event:

Did patient eat at restaurant(s) in the 14 days prior to onset of illness?
If “Yes,” please specify the name of the restaurant(s):
Name of Laboratory that reported test result.
CLIA (Clinical Laboratory Improvement Act) identifier for the laboratory that performed
the test.
Sending system-assigned local ID of the case investigation with which the subject is
associated. This field has been added to provide the mapping to the case/investigation
to which this lab result is associated. This field should appear exactly as it appears in
OBR-3 of the Case Notification.
A laboratory generated number that identifies the test/order instance.
Ordered Test Name is the lab test ordered by the physician. It will always be included
in an ELR, but there are many instances in which the user entering manual reports will
not have access to this information.
The date the specimen was collected.
This indicates the physical location, of the subject, where the specimen originated.
Examples include: Right Internal Jugular, Left Arm, Buttock, Right Eye, etc.
A laboratory generated number that identifies the specimen related to this test.
The medium from which the specimen originated. Examples include whole blood,
saliva, urine, etc.
Specimen details if specimen information entered as text.
Date Sample Received at Lab (accession date).
The date and time the sample was analyzed by the laboratory.
Date result sent from Reporting Laboratory.
The status of the lab report.
The lab test that was run on the specimen.
Results expressed as numeric value/quantitative result.
The unit of measure for numeric result value.
Coded qualitative result value (e.g., Positive, Negative).
The organism name as a test result. This element is used when the result was reported
as an organism.
Textual result value, used if result is neither numeric nor coded.
The Result Status is the degree of completion of the lab test.
The interpretation flag identifies a result that is not typical as well as how it's not
typical. Examples: Susceptible, Resistant, Normal, Above upper panic limits, below
absolute low.
The reference range from value allows the user to enter the value on one end of a
expected range of results for the test. This is used mostly for quantitative results.
The reference range to value allows the user to enter the value on the other end of a
valid range of results for the test. This is used mostly for quantitative results.
The technique or method used to perform the test and obtain the test results.
Examples: Serum Neutralization, Titration, dipstick, test strip, anaerobic culture.
Comments having to do specifically with the lab result test. These are the comments
from the NTE segment if the result was originally an Electronic Laboratory Report.
Date the isolate was received in state public health laboratory.

Explanation for missing result (e.g., clotting, quantity not sufficient, etc.)
Indicate whether the specimens were sent to CDC for genotyping.
If the specimen was sent to the CDC for genotyping, date on which the specimens were
sent.
Indicate whether the specimen was sent for strain identification.
If the specimen was sent for strain identification, indicate the strain.
Track Isolate functionality indicator
Patient status at specimen collection
Isolate received in state public health lab
Reason isolate not received
Reason isolate not received (Other)
Date received in state public health lab
State public health lab isolate id number
Case confirmed at state public health lab
What was the result of specimen testing using an antigen-based test (e.g. EIA or lateral
flow) at a clinical laboratory?
Name of antigen-based test used at clinical laboratory
Age of case-patient in months if patient is <1yr
Age of case-patient in years
What was the result of specimen testing using an antigen-based test (e.g. EIA or lateral
flow) at a state public health laboratory? Results from rapid card testing or EIA would
be entered here.
Name of antigen-based test used at state public health laboratory
Did the case-patient have bloody diarrhea (self reported) during this illness?
Did the case-patient have diarrhea (self-reported) during this illness?
Date of hospital admission for second hospitalization for this illness
Date of hospital discharge for second hospitalization for this illness
Date case was entered into site's database
Date case-pateint's specimen was received in laboratory for initial testing
Date case report form was completed
Case-patient's specimen collection date
If case-patient patient traveled internationally, date of departure from the U.S.
If case-patient traveled internationally, date of return to the U.S.
CDC FDOSS outbreak ID number
Did the case-patient have fever (self-reported) during this illness?
If case-patient was hospitalized, was s/he transferred to another hospital?
Did case-patient immigrate to the U.S.? (within 15 days of illness onset)
Was the case-patient interviewed by public health (i.e. state or local health
department) ?
Name of submitting laboratory
Ccase-patient's medical record number

For other pathogens: What was the result of specimen testing using another test at
CDC? Results from DFA, IFA or other tests would be entered here.
What was the result of specimen testing using another test at a clinical laboratory?
Results from DFA, IFA or other tests would be entered here.
Name of other test used at a clinical laboratory
What was the result of specimen testing using another test at a state public health
laboratory? Results from DFA, IFA or other tests would be entered here.
Name of other test used at a state public health laboratory
Type of outbreak that the case-patient was part of
Case-patient identification number
What was the result of specimen testing for diagnosis using PCR at CDC? (Do not enter
PCR results if PCR was performed for speciation or subtyping).
What was the result of specimen testing using PCR at a clinical laboratory? (where goal
of testing is primary detection not subtyping or speciation)
Name of PCR assay used
What was the result of specimen testing for diagnosis using PCR at the state public
health laboratory? (Do not enter PCR results if PCR was performed for speciation or
subtyping).
Unique identification number for person or patient
Unique identifier for laboratory result
Is all of the information for this case complete?
Was specimen or isolate forwarded to CDC for testing or confirmation?
State lab identification number
Case patient's specimen collection source
Was the isolate sent to a state public health laboratory? (Answer 'Yes' if it was sent to
any state lab, even if it was sent to a lab outside of the case's state of residence)
If case-patient traveled internationally, to where did they travel?
Did the case patient travel internationally? (within 15 days of onset)

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
PHVS_FreshProduce_FDD
PHVS_InterviewStatus_CDC
PHVS_TravelDestinationType_FDD
PHVS_TravelMode_CDC
PHVS_TravelPurpose_FDD

FDD_Q_77 (PHIN_Questions_FDD)
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_WeightUnit_UCUM
PHVS_WeightUnit_UCUM
PHVS_YesNoUnknown_CDC
PHVS_TemperatureUnit_UCUM
PHVS_CyclosporiasisSignsSymptoms_FDD

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_FreshBerries_FDD

PHVS_FreshHerbs_FDD

PHVS_LettuceType_FDD

PHVS_FreshProduce_FDD

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_BodySite_CDC

PHVS_Specimen_CDC

PHVS_ResultStatus_HL7_2x
PHVS_LabTestName_CDC
PHVS_UnitsOfMeasure_CDC
PHVS_LabTestResultQualitative_CDC
PHVS_Microorganism_CDC

PHVS_ObservationResultStatus_HL7_2x
PHVS_AbnormalFlag_HL7_2x

PHVS_LabTestMethods_CDC

PHVS_MissingLabResult_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_MicrobiologicalStrain_CDC
PHVS_TrueFalse_CDC
PHVS_PatientLocationStatusAtSpecimenCollection
PHVS_YesNoUnknown_CDC
PHVS_IsolateNotReceivedReason_NND

PHVS_YesNoUnknown_CDC

Label/Short Name
Childhood Primary Series?
Number of Doses if <18 years old
Boosters as Adult?
Last Dose
Clinical Description
Fever?
If Yes, Temp
Sore Throat?
Difficulty Swallowing?
Membrane?
If Yes, Tonsils?
If Yes, Soft Palate?
If Yes, Hard Palate?
If Yes, Larynx?
If Yes, Nares?
If Yes, Nasopharynx?
If Yes, Conjunctiva?
If Yes, Skin?
Change in Voice?
Shortness of Breath?
Weakness?
Fatigue?
Other?
Soft Tissue Swelling?
Neck Edema?
If Yes
If Yes, Extent
Stridor?
Wheezing?
Palatal Weakness?
Tachycardia?
EKG Abnormalities?
Complications?
Airway Obstruction?
AO Onset Date
Intubation Required?
Myocarditis?
Myocarditis Onset Date
(Poly)neuritis?
(Poly)neuritis Onset date
Other?
Describe
Diphtheria Culture

Culture Date
Culture Result
Lab Name
Biotype
Toxigenicity Test
Specimen Sent to CDC
Specimen Type
Serum Specimen for Ab Testing
PCR Result
Antibiotic Treatment
Outpatient Treatment
Date Initiated
Antibiotic as Outpatient
OP Therapy Duration
Antibiotic Therapy in Hospital
Inpatient Treatment
Antibiotic as Inpatient
IP Therapy Duration
Antibiotics Before Culture
Country of Residence
Other Country
US Arrival Date
International Travel
Country(s) Visited
International Departure Date
International Return Date
Interstate Travel
State(s) Visited
Interstate Departure Date
Interstate Return Date
Exposure to Case or Carrier?
Exposure to International Travelers?
Exposure to Immigrants?
DAT Administered
Final Diagnosis
Final Diagnosis Confirmation

Description
Did the patient receive primary a vaccination series?
If patient <18 years old, how many doses of vaccine were received?
Did the patient receive vaccine booster doses as an adult?
What is the date of patient's last dose of vaccine?
Description of patient's clinical picture
Did/does the patient have a fever?
The units of measure of the highest measured temperature in Celsius.
Did/does the patient have a sore throat?
Did/does the patient have difficulty swallowing?
Did/does the patient have a pseudomembrane?
Were/are the tonsils the site of the membrane?
Was/is the soft palate the site of the membrane?
Was/is the hard palate the site of the membrane?
Was/is the larynx the site of the membrane?
Were/are the nares the site of the membrane?
Was/is the nasopharynx the site of the membrane?
Was/is conjunctiva the site of the membrane?
Was/is the skin site of the membrane?
Did/does the patient experience shortness of breath?
Did/does the patient have voice change?
Did/does the patienthave weakness?
Did/does the patient have fatique?
Did/does the patient have any other symptoms?
Did/does the patient have soft tissue swelling?
Did/does the patient have neck edema?
If neck edema, was it bilateral, left side only, or right side only?
If neck edema, extent of the neck edema
Did/does the patient have stridor?
Did/does the patient have wheezing?
Did/does the patient have weakness?
Did/does the patient have tachycardia?
Did/does the patient have EKG abnormalities?
Did/does the patient have complications due to this illness?
Did/does the patient have airway obstruction as a complication of this illness?
Patient's onset date for airway obstruction
Was intubation of the patient required?
Did/does the patient have myocarditis as a complication of this illness?
Patient's onset date for myocarditis
Did/does the patient have (poly)neuritis as a complication of this illness?
Patient's onset date for (poly)neuritis
Did/does the patient experience any other complications due to this illness?
Description of other complications due to this illness.
Was a specimen for diphtheria culture obtained?

If yes, date culture specimen obtained
What is the result for culture specimen?
Specify laboratory performing culture
If culture result positive, specify biotype
If culture positive, what is the result of toxigenicity testing?
Was a specimen sent to the CDC Diphtheria Lab for confirmation/molecular typing?
Indicate type of specimen sent to CDC
Was a serum specimen for diphtheria antitoxin antibodies obtained?
Specify the PCR result
Was patient treated with antibiotics?
Did patient receive treatment as an outpatient?
If yes, what is the date outpatient treatment initiated?
What antibiotic did the patient receive?
What was the duration of therapy (in days)?
Was antibiotic therapy obtained in a hospital?
Did patient receive treatment as an inpatient?
What antibiotic did the patient receive?
What was the duration of therapy (in days)?
Did patient receive antibiotics in the 24 hours before culture specimen taken?
What is patient's country of residence?
If other than US, what is the country?
What is the date of patient's arrivaal in the US?
Did patient have history of international travel 2 weeks prior to symptom onset?
What country(s) were visited?
Date the patient left for international travel
Date the patient returned from international travel
Did patient have history of interstate travel 2 weeks prior to symptom onset?
What state(s) were visited?
Date the patient left for interstate travel
Date the patient returned from intestate travel
Was patient exposed to a known case or carrier of diphtheria?
Did the patient have a known exposure to any international travelers?
Did the patient have a known exposure to any immigrants?
Units of DAT administered
What was the final clinical diagnosis for this patient?
How was the final diagnosis confirmed?

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

Label/Short Name
Animal Contact Questions Indicator
Animal Contact Indicator
Animal Type Code(s)
Animal Type Other
Amphibian Other
Reptile Other
Mammal Other
Animal Contact Location
Acquired New Pet
Applicable Incubation Period
Associated with Daycare Indicator
Day Care Attendee
Day Care Worker
Live with Day Care Attendee
Day Care Type
Day Care Facility Name
Food Prepared at this Daycare
Diapered Infants at this Daycare
Drinking Water Exposure Indicator
Home Tap Water Source Code
Home Well Treatment Code
Home Tap Water Source Other
School/Work Tap Water Source Code
SchoolWork Well Treatment Code
School/Work Tap Water Source
Other
Drink Untreated Water 14 days Prior
to Onset
Food Handler
Food Handler after Illness Onset
Food HandlerLast Worked Date
Food Handler Location
Recreational Water Exposure
Questions Indicator
Recreational Water Exposure 14 Days
Prior to Onset
Recreational Water Exposure Type
Code(s)
Recreational Water Exposure Type
Other
Swimming Pool Type Code(s)
Swimming Pool Type Other
Recreational Water Location Name

Related Case Indicator
Patient Knows of Similarly Ill Persons
Health Department Investigated
Other Related Cases
Travel Questions Indicator
Travel Prior To Onset
Incubation Period
Travel Purpose Code(s)
Travel Purpose Other
Destination 1 Type:
(Domestic) Destination 1:
(International) Destination 1
Mode of Travel: (1)
Date Of Arrival (1)
Date of Departure (1)
Destination 2 Type
(Domestic) Destination 2
(International) Destination 2
Mode of Travel: (2)
Date of Arrival: (2)
Date of Departure (2)
Destination 3 Type:
(Domestic) Destination 3:
(International) Destination 3
Mode of Travel: (3)
Date of Arrival: (3)
Date of Departure (3)
Other Destination Txt
Reporting Lab Name
Reporting Lab CLIA Number
Local record ID (case ID)

Filler Order Number
Ordered Test Name

Date of Specimen Collection
Specimen Site
Specimen Number

Specimen Source
Specimen Details
Date Sample Received at Lab
Sample Analyzed date
Lab Report Date
Report Status
Resulted Test Name
Numeric Result
Result Units
Coded Result Value
Organism Name
Lab Result Text Value
Result Status
Interpretation Flag

Reference Range From
Reference Range To
Test Method
Lab Result Comments

Date received in state public health
lab
Lab Test Coded Comments
Genotyping/ Subtyping
Genotyping Sent Date
Genotype/Subtype location
Genotype
Subtype
Track Isolate
Patient status at specimen collection
Isolate received in state public health
lab
Reason isolate not received
Reason isolate not received (Other)
Date received in state public health
lab
State public health lab isolate id
number

Case confirmed at state public health
lab
AgClinic
AgClinicTestType
AgeMnth
AgeYr
AgSphl
AgSphlTestType
BloodyDiarr
Diarrhea
DtAdmit2
DtDisch2
DtEntered
DtRcvd
DtRptComp
DtSpec
DtUSDepart
DtUSReturn
EforsNum
Fever
HospTrans
Immigrate
Interview
LabName
LocalID
OtherCdcTest
OtherClinicTest
OtherClinicTestType
OtherSphlTest
OtherSphlTestType
OutbrkType
PatID
PcrCdc
PcrClinic
PcrClinicTestType
PcrSphl

PersonID

ResultID
RptComp
SentCDC
SLabsID
SpeciesClinic
SpeciesSphl
SpecSite
StLabRcvd

TravelDest
TravelInt

Description
If contact with animal, then display the following questions
Did patient come in contact with an animal?
Type of animal: (MULTISELECT)
If “Other,” please specify other type of animal:
If “Other Amphibian,” please specify other type of amphibian:
If “Other Reptile,” please specify other type of reptile:
If "Other Mammal," please specify other type of mammal:
Name or Location of Animal Contact:
Did the patient acquire a pet prior to onset of illness?
Applicable incubation period for this illness is
If Patient associated with a day care center:
Attend a day care center?
Work at a day care center?
Live with a day care center attendee?
What type of day care facility?
What is the name of the day care facility?
Is food prepared at this facility?
Does this facility care for diapered persons?
If patient has had Drinking Water exposure, then display the following questions
What is the source of tap water at home?
If “Private Well,” how was the well water treated at home?
If “Other,” specify other source of tap water at home:
What is the source of tap water at school/work?
If “Private Well,” how was the well water treated at school/work?
If “Other,” specify other source of tap water at school/work:
Did patient drink untreated water 14 days prior to onset of illness?
If patient is a Food Handler, then display the following questions
Did patient work as a food handler after onset of illness?
What was the last date worked as a food handler after onset of illness?
Where was patient a food handler?
If patient has had recreational water exposure, then display the following
Was there recreational water exposure in the 14 days prior to illness?
What was the recreational water exposure type? (MULTISELECT)
If "Other," please specify other recreational water exposure type:
If "Swimming Pool," please specify swimming pool type: (MULTISELECT)
If "Other," please specify other swimming pool type:
Name or location of water exposure:

If related cases are associated to this case, then display the following questions
Does the patient know of any similarly ill persons?
If "Yes," did the health department collect contact information about other similarly ill
persons and investigate further?
Are there other cases related to this one?
If patient has traveled, then display the following questions
Did the patient travel prior to onset of illness?
Applicable incubation period for this illness is 14 days
What was the purpose of the travel? (MULTISELECT)
If “Other,” please specify other purpose of travel:
Destination 1 Type:
(Domestic) Destination 1:
(International) Destination 1
Mode of Travel: (1)
Date of Arrival: (1)
Date of Departure (1)
Destination 2 Type
(Domestic) Destination 2
(International) Destination 2
Mode of Travel: (2)
Date of Arrival: (2)
Date of Departure (2)
Destination 3 Type:
(Domestic) Destination 3:
(International) Destination 3
Mode of Travel: (3)
Date of Arrival: (3)
Date of Departure (3)
If more than 3 destinations, specify details here:
Name of Laboratory that reported test result.
CLIA (Clinical Laboratory Improvement Act) identifier for the laboratory that performed
the test.
Sending system-assigned local ID of the case investigation with which the subject is
associated. This field has been added to provide the mapping to the case/investigation
to which this lab result is associated. This field should appear exactly as it ap
A laboratory generated number that identifies the test/order instance.
Ordered Test Name is the lab test ordered by the physician. It will always be included
in an ELR, but there are many instances in which the user entering manual reports will
not have access to this information.
The date the specimen was collected.
This indicates the physical location, of the subject, where the specimen originated.
Examples include: Right Internal Jugular, Left Arm, Buttock, Right Eye, etc.
A laboratory generated number that identifies the specimen related to this test.

The medium from which the specimen originated. Examples include whole blood,
saliva, urine, etc.
Specimen details if specimen information entered as text.
Date Sample Received at Lab (accession date).
The date and time the sample was analyzed by the laboratory.
Date result sent from Reporting Laboratory.
The status of the lab report.
The lab test that was run on the specimen.
Results expressed as numeric value/quantitative result.
The unit of measure for numeric result value.
Coded qualitative result value.
The organism name as a test result. This element is used when the result was reported
as an organism.
Textual result value, used if result is neither numeric nor coded.
The Result Status is the degree of completion of the lab test.
The interpretation flag identifies a result that is not typical as well as how it's not
typical. Examples: Susceptible, Resistant, Normal, Above upper panic limits, below
absolute low.
The reference range from value allows the user to enter the value on one end of a
expected range of results for the test. This is used mostly for quantitative results.
The reference range to value allows the user to enter the value on the other end of a
valid range of results for the test. This is used mostly for quantitative results.
The technique or method used to perform the test and obtain the test results.
Examples: Serum Neutralization, Titration, dipstick, test strip, anaerobic culture.
Comments having to do specifically with the lab result test. These are the comments
from the NTE segment if the result was originally an Electronic Laboratory Report.
Date the isolate was received in state public health laboratory.
Explanation for missing result (e.g., clotting, quantity not sufficient, etc.)
Indicate whether the specimens were genotyped and/or subtyped
If the specimen was sent to the CDC for genotyping, date on which the specimens were
sent.
Indicate where Genotype and/or subtype testing was performed
If the specimen was sent for genotype identification, indicate the genotype
If the specimen was sent for subtype idenfication, indicate the subtype
Track Isolate functionality indicator
Patient status at specimen collection
Isolate received in state public health lab
Reason isolate not received
Reason isolate not received (Other)
Date received in state public health lab
State public health lab isolate id number

Case confirmed at state public health lab
What was the result of specimen testing using an antigen-based test (e.g. EIA or lateral
flow) at a clinical laboratory?
Name of antigen-based test used at clinical laboratory
Age of case-patient in months if patient is <1yr
Age of case-patient in years
What was the result of specimen testing using an antigen-based test (e.g. EIA or lateral
flow) at a state public health laboratory?
Name of antigen-based test used at state public health laboratory
Did the case-patient have bloody diarrhea (self reported) during this illness?
Did the case-patient have diarrhea (self-reported) during this illness?
Date of hospital admission for second hospitalization for this illness
Date of hospital discharge for second hospitalization for this illness
Date case was entered into site's database
Date case-pateint's specimen was received in laboratory for initial testing
Date case report form was completed
Case-patient's specimen collection date
If case-patient patient traveled internationally, date of departure from the U.S.
If case-patient traveled internationally, date of return to the U.S.
CDC FDOSS outbreak ID number
Did the case-patient have fever (self-reported) during this illness?
If case-patient was hospitalized, was s/he transferred to another hospital?
Did case-patient immigrate to the U.S.? (within 15 days of illness onset)
Was the case-patient interviewed by public health (i.e. state or local health
department) ?
Name of submitting laboratory
Case-patient's medical record number
What was the result of specimen testing using another test at CDC?
What was the result of specimen testing using another test at a clinical laboratory?
Name of other test used at a clinical laboratory
What was the result of specimen testing using another test at a state public health
laboratory?
Name of other test used at a state public health laboratory
Type of outbreak that the case-patient was part of
Case-patient identification number
What was the result of specimen testing for diagnosis using PCR at CDC? (Do not enter
PCR results if PCR was performed for speciation or subtyping).
What was the result of specimen testing using PCR at a clinical laboratory? (where goal
of testing is primary detection not subtyping or speciation)
Name of PCR assay used
What was the result of specimen testing for diagnosis using PCR at the state public
health laboratory? (Do not enter PCR results if PCR was performed for speciation or
subtyping).
Unique identification number for person or patient

Unique identifier for laboratory result
Is all of the information for this case complete?
Was specimen or isolate forwarded to CDC for testing or confirmation?
State lab identification number
What was the species result at clinical lab?
What was the species result at SPHL?
Case patient's specimen collection source
Was the isolate sent to a state public health laboratory? (Answer 'Yes' if it was sent to
any state lab, even if it was sent to a lab outside of the case's state of residence)
If case-patient traveled internationally, to where did they travel?
Did the case patient travel internationally? (within 15 days of onset)

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
Yes No Indicator (HL7)
Yes No Unknown (YNU)
Animal Type (FDD)

Yes No Unknown (YNU)
Yes No Indicator (HL7)
Yes No Unknown (YNU)
Yes No Unknown (YNU)
Yes No Unknown (YNU)
Day CareType (FDD)
Yes No Unknown (YNU)
Yes No Unknown (YNU)
Yes No Indicator (HL7)
Tap Water Source (FDD)
Well Water Treatment (FDD)
Tap Water Source (FDD)
Well Water Treatment (FDD)

Yes No Unknown (YNU)
Yes No Indicator (HL7)
Yes No Unknown (YNU)

Yes No Indicator (HL7)
Yes No Unknown (YNU)
Recreational Water (FDD)

Swimming Pool Type (FDD)

Yes No Indicator (HL7)
Yes No Unknown (YNU)
Yes No Unknown (YNU)
Other Related Cases
Yes No Indicator (HL7)
Yes No Unknown (YNU)
Travel Purpose
Travel Destination Type
State
Country
Travel Mode

Travel Destination Type
State
Country
Travel Mode

Travel Destination Type
State
Country
Travel Mode

Ordered Test

Specimen

Specimen

Result Status (HL7)
Lab Test Result Name (FDD)
Units Of Measure
Lab Test Result Qualitative
Microorganism (FDD)

Observation Result Status (HL7)
Abnormal Flag (HL7)

Observation Method

Missing Lab Result Reason
Yes No Unknown (YNU)

Yes No Indicator (HL7)
Patient Location Status at Specimen Collection
Yes No Unknown (YNU)
Isolate Not Received Reason

Yes No Unknown (YNU)

Label/Short Name
DAYCARE
FACNAME
NURSHOME
NHNAME
SYNDRM
SPECSYN
SPECIES
OTHBUG1
STERSITE
OTHSTER
DATE
NONSTER
UNDERCOND
COND
OTHMALIG
OTHORGAN
OTHILL
OTHOTHSPC
Specify Internal Body Site
Other Prior Illness 2
Other Prior Illness 3
Other Nonsterile Site
INSURANCE
INSURANCEOTH
WEIGHTLB
WEIGHTOZ
WEIGHTKG
HEIGHTFT
HEIGHTIN
HEIGHTCM
WEIGHTUNK
HEIGHTUNK
SEROTYPE
HIBVACC
MEDINS
OTHINS
HIBCON
CONTYPE
SIGHIST
PREWEEKS
SPECHIV

OTHSIGHIST
ACUTESER
ACUTESERDT
CONVSER
CONVSERDT
BIRTHCTRY
Other Serotype
Was the patient < 15 years of age at
the time of first positive culture?

Description
If <6 years of age, is the patient in daycare?
Name of the daycare facility.
Does the patient reside in a nursing home or other chronic care facility?
Name of the nursing home or chronic care facility.
Types of infection that are caused by the organism. This is a multi-select field.
Other infection that is caused by the organism.
Bacterial species that was isolated from any normally sterile site.
Other bacterial species that was isolated from any normally sterile site.
Sterile sites from which the organism was isolated. This is a multi-select field.
Other sterile site from which the organism was isolated.
Date the first positive culture was obtained. (This is considered diagnosis date.)
Nonsterile sites from which the organism was isolated. This is a multi-select field.
Did the patient have any underlying conditions?
Underlying conditions that the subject has. This is a multi-select field.
Other malignancy that the subject had as an underlying condition.
Detail of the organ transplant that the subject had as an underlying condition.
Other prior illness that the subject had as an underlying condition.
Another Bacterial Species not listed in the Other Bacterial Species drop-down list.
Internal Body Site where the organism was located.
Other prior illness that the subject had as an underlying condition.
Other prior illness that the subject had as an underlying condition.
Other nonsterile site from which the organism was isolated.
Patient's type of insurance (multi-selection).
Patient's other type of insurance.
Weight of the patient in pounds.
Weight of the patient in ounces.
Weight of the patient in kilograms.
Height of the patient in feet.
Height of the patient in inches.
Height of the patient in centimeters.
Indicator that the weight of the patient is unknown.
Indicator that the height of the patient is unknown.
Serotype of the culture.
If <15 years of age and serotype is 'b' or 'unk', did the patient receive Haemophilus
Influenzae b vaccine?
Type of medical insurance the family has.
Other medical insurance type.
Is there a known previous contact with Hib disease within the preceding two months?
Type of previous contact with Hib disease within the preceding two months.
Patient's significant past medical history.
Number of weeks of a preterm birth (less than 37 weeks).
Specify immunosupression/HIV.

Specify other prior condition.
Is acute serum available?
Date of acute serum availability.
Is convalescent serum available?
Date of convalescent serum availability.
Person's country of birth.
Another serotype not included in the serotype dropdown list.
Indicator whether the patient was less than 15 years of age at the time of first positive
culture.

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
TBD
TBD
TBD
TBD

TBD
PHVS_YesNoUnknown_CDC
TBD

TBD

TBD

PHVS_TrueFalse_CDC
PHVS_TrueFalse_CDC
TBD
PHVS_YesNoUnknown_CDC
TBD
PHVS_YesNoUnknown_CDC

TBD

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_Country_ISO_3166-1
PHVS_YesNoUnknown_CDC

Label/Short Name
State Case ID
Date of completion of Report
Date of First Report to CDC
Notification Result Status
Condition Code
Case Class Status Code
MMWR Week
MMWR Year
Reporting State
Reporting County
National Reporting Jurisdiction
Reporting Source Type Code
Reporting Source ZIP Code
Date First Reported PHD
Person Reporting to CDC - Name

Person Reporting to CDC - Phone
Number
Person Reporting to CDC - Title

Person Reporting to CDC - Affiliation

Type of leprosy
Subject Address County
Subject Address State
Age units at case investigation
Country of Birth
Time in U.S.
Date first entered U.S.
Subject’s Sex
Race Category
Ethnic Group Code

Country of Usual Residence

Earliest Date Reported to County
Earliest Date Reported to State
Diagnosis Date
Case Disease Imported Code
Imported Country
Country of Exposure or Country
Where Disease was Acquired
Note: use exposure or acquired
consistently across variables
Date of Onset of symptoms
Date Leprosy first diagnosed
Initial diagnosis
Diagnosis_Biopsy
Diagnosis_SkinSmear
Date test performed
Test Result
Current antimicrobial Treatment
Date current antimicrobial Treatment
Disability
Armadillo exposure

Description
States use this field to link NEDSS investigations back to their own state investigations.
Date the initial leprosy surveillance form was completed by a reporting source
(physician or lab reported to the local/county/state health department).
Date the case was first reported to the CDC
Status of the notification.
Condition or event that constitutes the reason the notification is being sent
Status of the case/event as suspect, probable, confirmed, or not a case per CSTE/CDC/
surveillance case definitions.
MMWR Week for which case information is to be counted for MMWR publication.
MMWR Year (YYYY) for which case information is to be counted for MMWR
publication.
State reporting the notification.
County reporting the notification.
National jurisdiction reporting the notification to CDC.
Type of facility or provider associated with the source of information sent to Public
Health.
ZIP Code of the reporting source for this case.
Earliest date the case was reported to the public health department whether at the
local, county, or state public health level.
Name of the person who is reporting the case to the CDC. This is the person that CDC
should contract in a state if there are questions regarding this case notification.
Phone Number of the person who is reporting the case to the CDC. This is the person
that CDC should contract in a state if there are questions regarding this case
notification.
Job title / description of the person reporting the case to the CDC. This is the person
that CDC should contract in a state if there are questions regarding this case
notification.
Affiliated Facility of the person reporting the case to the CDC. This is the person that
CDC should contract in a state if there are questions regarding this case notification.
Classify the diagnosis based on one of the ICD-9-CM diagnosis codes
County of residence of the subject
State of residence of the subject
Subject age units at time of case investigation
Country of Birth
Length of time this subject has been living in the U.S. (if born out of the U.S.
Provide the date that subject first entered U.S. in YYYYMM format (if born out of the
U.S.)
Subject’s current sex
Field containing one or more codes that broadly refer to the subject’s race(s).
Based on the self-identity of the subject as Hispanic or Latino

Where does the person usually* live (defined as their residence)
*For the definition of ‘usual residence’ refer to CSTE position statement # 11-SI-04
titled “Revised Guidelines for Determining Residency for Disease Reporting” at
http://www.cste.org/ps2011/11-SI-04.pdf .
Earliest date reported to county public health system
Earliest date reported to state public health system
Earliest date of diagnosis (clinical or laboratory) of condition being reported to public
health system
Indication of where the disease/condition was likely acquired.
If the disease or condition was imported, indicates the country in which the disease
was likely acquired.
Indicates the country in which the disease was potentially acquired.

Date of the beginning of the illness. Reported date of the onset of symptoms of the
condition being reported to the public health system
Provide month and year first diagnosis was made (if applicable)
Was subject diagnosed in the U.S. or outside the U.S.
Was biopsy performed in the U.S.?
Was skin smear test performed
Provide date test was performed in YYYYMM format
Epidemiologic interpretation of the results of the tests performed for this case
Indicate all antimicrobial drugs used to treat subject
Indicate the date antimicrobial treatment started
Indicate any sensory abnormalities or deformities of the hands, feet or eyes
Did subject ever had direct contact with an armadillo?

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

PHVS_ResultStatus_NETSS
PHVS_NotifiableEvent_Disease_Condition_CDC_NNDSS
PHVS_CaseClassStatus_NND

PHVS_State_FIPS_5-2
PHVS_County_FIPS_6-4
PHVS_NationalReportingJurisdiction_NND
PHVS_ReportingSourceType_NND

PHVS_TypeofLeprosy_CDC
PHVS_County_FIPS_6-4
PHVS_State_FIPS_5-2
PHVS_AgeUnit_UCUM_NETSS
PHVS_CountryofBirth_CDC

PHVS_Sex_MFU
PHVS_RaceCategory_CDC
PHVS_EthnicityGroup_CDC_Unk

PHVS_CountryofBirth_CDC

PHVS_DiseaseAcquiredJurisdiction_NETSS
PHVS_Country_ISO_3166-1
PHVS_CountryofBirth_CDC

PHVS_DiagnosisBiopsy_CDC
PHVS_DiagnosisSkinSmear_Leprosy
PHVS_LabTestInterpretation_Leprosy
PHVS_MedicationTreatment_Leprosy
PHVS_MedicationTreatment_Date_Leprosy
PHVS_HandsFeet_CDC
PHVS_YesNoUnknown_CDC

Label/Short Name
Last Name
First Name
Middle Initial
Occupation
History of rodent exposure 8 weeks prior to illness onset
If yes, type of rodent exposure
Exposre occurred while cleaning
Exposure occurred while working
Exposre during recreational activity (camping, hiking)
Other exposure? (explain below)
Fever >101F (38.3C)
Thrombocytopenia (<150,000)
Elevated hematocrit
Elevated creatinine
Outcome of illness
Autopsy performed
Autopsy findings
Did patient seek care before admission
Date of pre-hospital treatment
Outcome of treatment (sent home, diagnosed as flu, etc):
Supplemental oxygen required
Was patient on ECMO
Was patient intubated
CXR with unexplained bilateral interstitial infiltrates or suggestive of ARDS
Notes on clinical course of illness
Specimen collection date
Type of specimen
If specimen tested, at which laboratory
Test results (i.e. titer, IgM, IgG)
Name of patient’s physician
Physician's email
Physician's phone number

Description
Patient's last name
Patient's first name
Patient's middle initial
Patient's occupation
Did patient have history of rodent exposure during 8 week period prior to illness onset?
If rodent exposure occurred, what was the type of exposure?
Did exposure occur while cleaning?
Did exposure occur while working?
Did exposure occur during a recreational activity?
Other types of exposure? (Explain)
Did patient have a fever >101F (38.3C)?
Did patient have thrombocytopenia (<150,000)?
Did patinent have elevated hematocrit?
Did patinet have elevated creatinine?
What was the outcome of the illness?
If patient died, was autopsy performed?
Describe autopsy findings
Did patient seek care before admission?
Date of pre-hospital treatment
What was the outcome of treatment (sent home, diagnosed as flu, etc)?
Did the patient require supplemental oxygen?
Was patient on extracorporeal membrane oxygenation (ECMO)?
Was the patient intubated?
Did patient have chest x-ray (CXR) with unexplained bilateral interstitial infiltrates or suggestive of acute respiratory distres
Describe clinical course of illness
Specimen collection date
Type of specimen collected
If specimen tested, at which laboratory?
Test results (i.e. titer, IgM, IgG)
Name of patient’s physician
Physician's email
Physician's phone number

Label/Short Name
Reason for Testing
Symptomatic
Date of Illness Onset
Jaundiced (Symptom)
Due Date
Previously Aware of Condition
Provider of Care for Condition
Liver Enzyme Test Type
Liver Enzyme Test Result Date
Liver Enzyme Upper Limit Normal
Liver Enzyme Test Result
Test Type
Test Result
anti-HCV signal to cut-off ratio
Is this case Epi-linked to another
confirmed or probable case?
Contact With Confirmed or
Suspected Case
Contact Type
Contact Type Indicator

In Day Care
Day Care Contact
Identified Day Care Case
Sexual Preference
Number of Male Sexual Partners
Number of Female Sexual Partners
IV Drug Use
Recreational Drug Use
Travel or Live Outside U.S. or Canada
Countries Traveled or Lived Outside
U.S. or Canada

Principal reason for travel
Household Travel Outside U.S. or
Canada
Household Countries Traveled to
Outside U.S. or Canada
Common-Source Outbreak
Foodborne Outbreak- infected food
handler
Foodborne Outbreak - NOT an
infected food handler
Food Item of Associated Outbreak
Waterborne Outbreak
Unidentified Source Outbreak
Food Handler
Diabetes
Diabetes Diagnosis Date
Ever Receive a Vaccine
Total Doses of Vaccine
Date of Last Dose
Ever Receive Immune Globulin
Date of Last IG Dose
Mother's Race
Mother's Ethnicity
Mother Born Outside U.S.
Mother's Birth Country
Mother Confirmed Positive Prior To
Delivery
Mother Confirmed Positive After
Delivery
Mother Confirmed Positive Date
Total Doses of Vaccine
Ever Receive Immune Globulin
Date the child received HBIG
Vaccine Dose Number
Vaccine Administered Date
Contact With Confirmed or
Suspected Case

Contact Type

Contact Type Indicator

Sexual Preference
Number of Male Sexual Partners

Number of Female Sexual Partners

Number of Sex Partners
Treated for STD
Year of Recent Treatment for STD

Ever IDU
Ever Had Contact with Hepatitis
Ever Contact Type
IV Drug Use

Recreational Drug Use

Long-Term Hemodialysis

Hemodialysis

Contaminated Stick

Transfusion before 1992
Transplant before 1992
Clotting Factor before1987
Blood Transfusion

Blood Transfusion Date

Outpatient IV Infusions and/or
Injections

Other Blood Exposure

Ever a Medical / Dental Blood
Worker
Medical / Dental Blood Worker

Medical / Dental Blood Worker Frequency of Blood Contact

Public Safety Blood Worker

Public Safety Blood Worker Frequency of Blood Contact

Tattoo

Location Tattoo Received from
Piercing

Location Piercing Received from
Dental Work / Oral Surgery

Surgery Other Than Oral

Tested for Hepatitis D
Hepatitis Delta Infection
Prior Negative Hepatitis Test

Verified Test Date
Hospitalized

Long Term Care Resident

Ever Incarcerated
Incarcerated More Than 24 hours

Diabetes
Diabetes Diagnosis Date
Type of Incarceration Facility
Incarceration Type Indicator
Incarcerated More Than 6 months
Year of Most Recent Incarceration
Length of Incarceration
Received Medication for Condition
Mother's Birth Country
Did the subject ever receive a
vaccine?
Total Doses of Vaccine
Date of Last Dose
Tested for HBsAg Antibodies
HBsAg Antibodies Positive

Description
Listing of the reason(s) the subject was tested for hepatitis.
Was the subject symptomatic for hepatitis?
Date of the beginning of the illness. Reported date of the onset of symptoms of the
condition being reported to the public health system
Was the subject jaundiced?
Subject's pregnancy due date
Was the subject aware they had Hepatitis prior to lab testing?
Does the subject have a provider of care for Hepatitis? This is any healthcare provider
that monitors or treats the patient for viral hepatitis.
Liver Enzyme Test Type
Liver Enzyme Test Result Date
Liver Enzyme Upper Limit Normal
Liver Enzyme Test Result
Epidemiologic interpretation of the type of test(s) performed for this case.
Epidemiologic interpretation of the results of the test(s) performed for this case.
Used to specify the anti-HCV signal to cut-off ratio if antibody to Hepatitis C virus was
the test performed.
Specify if this case is Epidemiologically-linked to another confirmed or probable case of
hepatitis?
During the 2-6 weeks prior to the onset of symptoms, was the subject a contact of a
person with confirmed or suspected hepatitis virus infection?
During the 2-6 weeks prior to the onset of symptoms, type of contact the subject had
with a person with confirmed or suspected hepatitis virus infection
During the 2-6 weeks prior to the onset of symptoms, answer (Yes, No, Unknown) for
each type of contact the subject had with a person with confirmed or suspected
hepatitis virus infection
During the 2-6 weeks prior to the onset of symptoms, was the subject a child or
employee in daycare center, nursery, or preschool?
During the 2-6 weeks prior to the onset of symptoms, was the subject a household
contact of a child or employee in a daycare center, nursery, or preschool?
Was there an identified hepatitis case in the childcare facility?
What is/was the subject's sexual preference?
During the 2-6 weeks prior to the onset of symptoms, number of male sex partners the
person had.
During the 2-6 weeks prior to the onset of symptoms, number of female sex partners
the person had.
During the 2-6 weeks prior to the onset of symptoms, did the subject inject drugs not
prescribed by a doctor?
During the 2-6 weeks prior to the onset of symptoms, did the subject use street drugs
but not inject?
During the 2-6 weeks prior to the onset of symptoms, did the subject travel or live
outside the U.S.A. or Canada?
The country(s) to which the subject traveled or lived (outside the U.S.A. or Canada)
prior to symptom onset.

What was the principal reason for travel?
During the 3 months prior to the onset of symptoms, did anyone in the subject's
household travel outside the U.S.A. or Canada?
The country(s) to which anyone in the subject's household traveled (outside the U.S.A.
or Canada) prior to symptom onset.
Is the subject suspected as being part of a common-source outbreak?
Subject is associated with a foodborne outbreak that is asscociated with an infected
food handler.
Subject is associated with a foodborne outbreak that is not associated with an infected
food handler.
Food item with which the foodborne outbreak is associated.
Subject is associated with a waterborne outbreak .
Subject is associated with an outbreak that does not have an identifed source.
During the 2 weeks prior to the onset of symptoms or while ill, was the subject
employed as a food handler?
Does subject have diabetes?
If subject has diabetes, date of diabetes diagnosis.
Did the subject ever receive the hepatitis A vaccine?
Number of doses of hepatitis A vaccine the subject received.
Year the subject received the last dose of hepatitis A vaccine.
Has the subject ever received immune globulin?
Date the subject received the last dose of immune globulin.
Race of the subject's mother.
Ethnicity of the patient's mother.
Was mother born outside of the United States of America?
What is the birth country of the mother?
Was the mother confirmed HBsAg positive prior to or at time of delivery?
Was the mother confirmed HBsAg positive after delivery?
Date of mother's earliest HBsAg positive test result.
Number of doses of hepatitis vaccine the child received.
Has the child ever received immune globulin?
Date the child received the last dose of immune globulin.
The vaccine dose number in series of vaccination for hepatitis.
The date that the vaccine was administered.
For Acute Hepatitis B, in the 6 weeks to 6 months prior to onset of symptoms, was the
patient a contact of a person with confirmed or suspected hepatitis B virus infection?
For Acute Hepatitis C, in the 2 weeks to 6 months prior to onset of symptoms, was the
patient a contact of a person with confirmed or suspected hepatitis C virus infection?

For Acute Hepatitis B, in the 6 weeks to 6 months prior to onset of symptoms, type of
contact with a person with confirmed or suspected hepatitis B virus infection?
For Acute Hepatitis C, in the 2 weeks to 6 months prior to onset of symptoms, type of
contact with a person with confirmed or suspected hepatitis C virus infection?
For Acute Hepatitis B, in the 6 weeks to 6 months prior to onset of symptoms, answer
(Yes, No, Unknown) for each type of contact the subject had with a person with
confirmed or suspected hepatitis B virus infection.
For Acute Hepatitis C, in the 2 weeks to 6 months prior to onset of symptoms, answer
(Yes, No, Unknown) for each type of contact the subject had with a person with
confirmed or suspected hepatitis B virus infection.
What is/was the subject's sexual preference?
Prior to the onset of symptoms, number of male sex partners the person had.
For Acute Hep B, the time period prior to onset of symptoms is 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 6 months.
Prior to the onset of symptoms, number of female sex partners the person had.
For Acute Hep B, the time period prior to onset of symptoms is 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 6 months.
How many sex partners (approximately) has subject ever had?
Was the subject ever treated for a sexually transmitted disease?
Year the patient received the most recent treatment for a sexually transmitted disease.

Has the patient ever injected drugs not prescribed by a doctor, even if only once or a
few times?
Was the patient ever a contact of a person who had hepatitis?
If the patient was ever a contact of a person who had hepatitis, what was the type of
contact?
Prior to the onset of symptoms, did the patient inject drugs not prescribed by a
doctor?
For Acute Hep B, the time period prior to onset of symptoms is 6 weeks - 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 2 weeks - 6 months.

Prior to the onset of symptoms, did the patient use street drugs but not inject?
For Acute Hep B, the time period prior to onset of symptoms is 6 weeks - 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 2 weeks - 6 months.

Was the patient ever on long-term hemodialysis?

Prior to the onset of symptoms, did the patient udergo hemodialysis?
For Acute Hep B, the time period prior to onset of symptoms is 6 weeks - 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 2 weeks - 6 months.

Prior to the onset of symptoms, did the patient have an accidental stick or puncture
with a needle or other object contaminated with blood?
For Acute Hep B, the time period prior to onset of symptoms is 6 weeks - 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 2 weeks - 6 months.

Did the patient receive a blood transfusion prior to 1992?
Did the patient receive an organ transplant prior to 1992?
Did the patient receive clotting factor concentrates prior to 1987?
Prior to the onset of symptoms, did the patient receive blood or blood products
(transfusion)?
For Acute Hep B, the time period prior to onset of symptoms is 6 weeks - 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 2 weeks - 6 months.

Date the subject began receiving blood or blood products (transfusion) prior to
symptom onset.
For Acute Hep B, the time period prior to onset of symptoms is 6 weeks - 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 2 weeks - 6 months.

Prior to the onset of symptoms, did the patient receive any IV infusions and/or
injections in an outpatient setting?
For Acute Hep B, the time period prior to onset of symptoms is 6 weeks - 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 2 weeks - 6 months.

Prior to the onset of symptoms, did the patient have other exposure to someone else's
blood?
For Acute Hep B, the time period prior to onset of symptoms is 6 weeks - 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 2 weeks - 6 months.

Was the patient ever employed in a medical or dental field involving direct contact
with human blood?
Prior to the onset of symptoms, was the patient employed in a medical or dental field
involving direct contact with human blood?
For Acute Hep B, the time period prior to onset of symptoms is 6 weeks - 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 2 weeks - 6 months.

Subject's frequency of blood contact as an employee in a medical or dental field
involving direct contact with human blood.
For Acute Hep B, the time period prior to onset of symptoms is 6 weeks - 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 2 weeks - 6 months.

Prior to the onset of symptoms, was the subject employed as a public safety worker
(fire fighter, law enforcement, or correctional officer) having direct contact with human
blood?
For Acute Hep B, the time period prior to onset of symptoms is 6 weeks - 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 2 weeks - 6 months.

Subject's frequency of blood contact as a public safety worker (fire fighter, law
enforcement, or correctional officer) having direct contact with human blood.
For Acute Hep B, the time period prior to onset of symptoms is 6 weeks - 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 2 weeks - 6 months.

Prior to the onset of symptoms, did the patient receive a tattoo?
For Acute Hep B, the time period prior to onset of symptoms is 6 weeks - 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 2 weeks - 6 months.

Location(s) where the patient received a tattoo
Prior to the onset of symptoms, did the patient receive a piercing (other than ear)?
For Acute Hep B, the time period prior to onset of symptoms is 6 weeks - 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 2 weeks - 6 months.

Location(s) where the patient received a piercing (other than ear)
Prior to the onset of symptoms, did the patient have dental work or oral surgery?
For Acute Hep B, the time period prior to onset of symptoms is 6 weeks - 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 2 weeks - 6 months.

Prior to the onset of symptoms, did the patient have surgery (other than oral surgery)?
For Acute Hep B, the time period prior to onset of symptoms is 6 weeks - 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 2 weeks - 6 months.

Was the patient tested for Hepatitis D
Did patient have a co-infection with Hepatitis D?
Did the patient have a negative hepatitis-related test in the previous 6 months?
For Hep B: Did patient have a negative HBsAg test in the previous 6 months?
For Hep C: Did patient have a negative HCV antibody test in the previous 6 months?
If patient had a negative hepatitis-related test test in the previous 6 months, please
enter the test date.
Prior to the onset of symptoms, was the patient hospitalized?
For Acute Hep B, the time period prior to onset of symptoms is 6 weeks - 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 2 weeks - 6 months.

Prior to the onset of symptoms, was the patient a resident of a long-term care facility?
For Acute Hep B, the time period prior to onset of symptoms is 6 weeks - 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 2 weeks - 6 months.

Was the patient ever incarcerated?
Prior to the onset of symptoms, was the patient incarcerated for longer than 24 hours?
For Acute Hep B, the time period prior to onset of symptoms is 6 weeks - 6 months.
For Acute Hep C, the time period prior to onset of symptoms is 2 weeks - 6 months.

Does subject have diabetes?
If subject has diabetes, date of diabetes diagnosis.
Type of facility where the patient was incarcerated for longer than 24 hours before
symptom onset.
Was the patient ever incarcerated for longer than six months during his or her
lifetime?
Year the patient was most recently incarcerated for longer than six months.
Length of time the patient was most recently incarcerated for longer than six months.
Has the subject ever received medication for the type of Hepatitis being reported?
What is the birth country of the mother?
Did the subject ever receive a hepatitis B vaccine?
Number of doses of hepatitis B vaccine the patient received.
Year the patient received the last dose of hepatitis B vaccine.
Was the patient tested for antibody to HBsAg (anti-HBs) within one to two months
after the last dose?
Was the serum anti-HBs >= 10ml U/ml? (Answer 'Yes' if lab result reported as positive
or reactive.)

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
PHVS_ReasonForTest_Hepatitis
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_LabTestTypeEnzymes_Hepatitis

PHVS_LabTestType_Hepatitis
PHVS_PosNegUnk_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_ContactType_HepatitisA
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_SexualPreference_NETSS

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_Country_ISO_3166-1

PHVS_TravelReason_HepatitisA
PHVS_YesNoUnknown_CDC
PHVS_Country_ISO_3166-1
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_RaceCategory_CDC
PHVS_EthnicityGroup_CDC_Unk
PHVS_YesNoUnknown_CDC
PHVS_Country_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_ContactType_HepatitisBandC

PHVS_YesNoUnknown_CDC

PHVS_SexualPreference_NETSS

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_ContactType_HepatitisBandC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_BloodContactFrequency_Hepatitis

PHVS_YesNoUnknown_CDC

PHVS_BloodContactFrequency_Hepatitis

PHVS_YesNoUnknown_CDC

PHVS_TattooObtainedFrom_Hepatitis
PHVS_YesNoUnknown_CDC

PHVS_TattooObtainedFrom_Hepatitis
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_IncarcerationType_Hepatitis
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_Country_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

Label/Short Name
CASEID
FIRST_IDENT
DATE_AS
OTHR_IDENT_DESC
HDD
HDD_DATE
DATEHUS
OUTBREAK
DIARRHEA
DONSET
STOOLBLOOD
DTREATED
A1ANTI
CONTACT

OTHREA
A3ANTI
A4REAS
GASTRO
UTI
RTI
ACUTE
DACUTE
PREG
KIDN
IMMCOMP
MALIG
TRANSPL
HIV
STER
IMMOTHER
CRE

BUN
WBC
HGB
HCT
PLT
RCFRAG

BURINE
PURINE
RBCURINE
STOOLSPEC
TESTSHIGA
N11BRESULT
STSPEC
STECPOS
CULTO157
DATEO157
O157ISOL
DATEO157POS
HANT
HANT_OTHER
STOOL_CDC_PHL
SPEC_DATEPHLSTEC
STEC_ISOL
O
H
O2
H2
IMS
IMS_SERO
OTHERPATH
PATH1
PATH1D

PATH2
PATH2D
PATHNOS
DESPATH
SPECPATH
DATEPATH
STATELAB
F9MENUREF
CDC
CDC_ID
REFLAB
SPECIFY_REFLAB
FNCATCH
PERSONID
ANTIO157
SLABID_SERUM
OTHERSLABSID_SERUM
LPS_TYPE1
IGG_1
IGG_INTERP
IGM_1
IGM1_INTERP
LPS_TYPE2
IGG_2
IGG_INTERP2
IGM_2
IGM1_INTERP2
LPS_TYPE3
IGG_3
IGG_INTERP3
IGM_3
IGM1_INTERP3
ADMISR
DISCHR
PNE
DPNE
SZR
DSZR
PAR
DPAR

BLN
DBLN
NER
DNER
DESCR1
PDIAL
HDIAL
PRBC
PLTT
FFPL
PHRES
SURG
SURGDES
CONDDC
DEAD
REQDIAL
NEURODEF

Description
Case patient's ID
How was patient's illness first identified by public health (state or local health
department or EIP)?
Date case entered into data system (Complete if FIRST_IDENT=1)
Describe other way patient's illness first identified by public health (Complete if
FIRST_IDENT=4).
Was this case captured through Hospital Discharge Data?
Date case entered into data system (Complete if HDD=1)
Date of HUS diagnosis
Is this case outbreak-related?
Did patient have diarrhea during the 3 weeks before HUS diagnosis?
Date of diarrhea (Complete if DIARRHEA=1)
Did stools contain visible blood at any time? (Complete if DIARRHEA=1)
Was diarrhea treated with antimicrobial medications/ (Complete if DIARRHEA=1)
Type of antimicrobial (Complete if DTREATED=1)
Did the patient have contact with another person with diarrhea or HUS during the 3
weeks before HUS diagnosis (include daycare, household, etc)? (Complete if
DIARRHEA=2)
Was patient treated with an antimicrobial medication for any other reason than
diarrhea during the 3 weeks before HUS diagnosis?
Type of antimicrobial (Complete if OTHREA=1)
Reason for antimicrobial (Complete if OTHREA=1)
Was other gastrointestinal illness present during 3 weeks before HUS diagnosis?
Did patient have a urinary tract infection during 3 weeks before HUS diagnosis?
Did patient have a respiratory tract infection during 3 weeks before HUS diagnosis?
Did patient have other acute illness during 3 weeks before HUS diagnosis?
Describe other acute illness (Complete if ACUTE=1)
Was patient pregnant during 3 weeks before HUS diagnosis?
Did patient have kidney disease during 3 weeks before HUS diagnosis?
Did patient have an ummunocompromising condition or was the patient taking
medication during 3 weeks before HUS diagnosis?
Did patient have a malignancy during 3 weeks before HUS diagnosis? (Complete if
IMMCOMP=1)
Did patient have transplanted organ or bone marrow during 3 weeks before HUS
diagnosis? (Complete if IMMCOMP=1)
Did patient have HIV infection during 3 weeks before HUS diagnosis? (Complete if
IMMCOMP=1)
Was patient using steroids (parenteral or oral) during 3 weeks before HUS diagnosis?
(Complete if IMMCOMP=1)
Describe other immunocompromising condition during 3 weeks before HUS diagnosis?
(Complete if IMMCOMP=1)
Laboratory values within 7 days before and 3 days after HUS diagnosis: Highest serum
creatinine (expressed as mg/dL)

Laboratory values within 7 days before and 3 days after HUS diagnosis: Highest serum
BUN (expressed as mg/dL)
Laboratory values within 7 days before and 3 days after HUS diagnosis: Highest serum
WBC (expressed as K/mm3)
Laboratory values within 7 days before and 3 days after HUS diagnosis: Lowest
hemoglobin (expressed as g/dL)
Laboratory values within 7 days before and 3 days after HUS diagnosis: Lowest
hematocrit (expressed as %)
Laboratory values within 7 days before and 3 days after HUS diagnosis: Lowest platelet
count (expressed as K/mm3)
Were there microangiopathic changes (i.e., schistocytes, helmet cells or red cell
fragments) at any time within 7 days before HUS diagnosis to hospital discharge (if
patient was not hospitalized or discharged within 3 days of HUS diagnosis, then
outpatient lab results from 7 days before to 3 days after diagnosis should be used, if
available)
Other laboratory findings within 7 days before and 3 days after HUS diagnosis: Blood
(or heme) in urine
Other laboratory findings within 7 days before and 3 days after HUS diagnosis: Protein
in urine
Other laboratory findings within 7 days before and 3 days after HUS diagnosis: RBC in
urine by microscopy
Was a stool specimen obtained from this patient?
Was stool tested for Shiga toxin at any clinical laboratory?
Result of Shiga toxin testing (Complete if TESTSHIGA=1)
Collection date of first specimen tested (Complete if TESTSHIGA=1)
Collection date of first positive specimen (Complete if TESTSHIGA=1)
Was stool cultured for E. coli O157 (on selective or differential media e.g. SMAC,
CHROMagar O157, CTSMAC) at any CLINICAL laboratory?
Date stool cultured for E. coli O157 (Complete if CULTO157=1)
Was E.coli O157 isolated? (Complete if CULTO157=1)
Collection date 1st positive specimen culture for O157 (Complete if O157POS=1)
Result of H antigen testing (Complete if O157ISOL=1)
Other H antigen (Complete if HANT=5)
Was a stool sample, or any type of specimen or isolate originating from stool sent to a
public health laboratory (state or CDC)?
Date of specimen collection (Complete if STOOL_CDC_PHL=1)
Was E.coli or non-O157 STEC identified? (Complete if STOOL_CDC_PHL=1)
What was the O antigen for strain 1? (Complete if STEC_ISOL=1)
What was the H antigen for strain 1? (Complete if STEC_ISOL=1)
What was the O antigen for strain 2? (Complete if STEC_ISOL=1)
What was the H antigen for strain 2? (Complete if STEC_ISOL=1)
Was immunomagnetic separation (IMS) used to identify common STEC serogroups?
What serogroup(s) did the IMS procedure target? (Complete if IMS=1)
Was another pathogen isolated from stool (at PHL or clinical lab)?
Name pathogen isolated from stool (Complete if OTHERPATH=1)
Date other pathogen isolated from stool

Name of second pathogen isolated from stool (Complete if OTHERPATH=1)
Date second other pathogen isolated from stool
Was pathogen isolated from source other than stool (at PHL or clinical lab)?
Name pathogen isolated from source other than stool (Complete if PATHNOS=1)
Specimen source of pathogen isolated from source other than stool (Complete if
PATHNOS=1)
First date of isolation of pathogen from source other than stool (Complete if
PATHNOS=1)
If O157 or other STEC was isolated, was the isolate sent to state laboratory?
If isolate sent to state laboratory, what was the state laboratory ID (Complete if
STATELAB=1)
If O157 or other STEC was isolated, was the isolate sent to CDC?
If isolate sent to CDC, what was the CDC laboratory ID (Complete if CDC=1)
If O157 or other STEC was isolated, was the isolate sent to another reference lab?
If isolate sent to reference lab, what was the name of the reference lab? (Complete if
REFLAB=1)
Is the patient a resident of the FoodNet catchment area?
What is the FoodNet PERSONID? (Complete if FNCATCH=1)
Has patient serum or plasma been sent to CDC for testing for antibodies to O157 or
other STEC?
What is the state laboratory ID or the serum? (Complete if ANTIO157=1)
Other laboratory ID numbers for serum sent to CDC (Complete if ANTIO157=1)
LPS type
IgG titer
Interpretation of IgG titer
IgM titer
Interpretation of IgM titer
Second LPS type
Second IgG titer
Interpretation of second IgG titer
Second IgM titer
Interpretation of second IgM titer
Third LPS type
Third IgG titer
Interpretation of third IgG titer
Third IgM titer
Interpretation of third IgM titer
Date of first hospital admission
Date of last hospital discharge
Did pneumonia occur as a complication during this hospital admission?
Date of onset of pneumonia (Complete if PNE=1)
Did seizure occur as a complication during this hospital admission?
Date of onset of seizure (Complete if SZR=1)
Did paralysis or hemiparesis occur as a complication during this hospital admission?
Date of onset of paralysis or hemiparesis (Complete if PAR=1)

Did blindness occur as a complication during this hospital admission?
Date of onset of blindness (Complete if BLN=1)
Did other major neurologic sequelae occur as a complication during this hospital
admission?
Date of other major neurologic sequalae (Complete if NER=1)
Describe other major neurologic sequelae (Complete if NER=1)
Was peritoneal dialysis performed during hospital stay?
Was hemodialysis performed during hospital stay?
Was packed RBC or whole blood used in dialysis? (Complete if PDIAL=1 or HDIAL=1)
Were platelets used in dialysis? (Complete if PDIAL=1 or HDIAL=1)
Was fresh frozen plasma used in dialysis? (Complete if PDIAL=1 or HDIAL=1)
Was plasmapheresis performed during hospital stay?
Was laparotomy or other abdominal surgery performed during hospital stay? Do not
include insertion of dialysis catheter.
Describe other abdominal surgery
Patient's condition at hospital discharge
Date of death (Complete if CONDDC=1)
Was patient discharged requiring dialysis? (Complete if CONDDC=2)
Was patient discharged with neurologic deficits? (Complete if CONDDC=2)

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

Label/Short Name
City
State
Country
Occupation
Gender
Age
Race
Ethnicity
Animal Exposure
Animal Species
Animal State
Animal Country
Type of Exposure
Vaccination status
Travel
Travel State
Travel Country
Travel DateStart
Travel DateEnd
Onset
Hospitalized
Death
Variant

Description
Patients City of Residence
Patients State of Residence
Patients Country of Residence
Patients Occupation
Patients Gender
Patients Age
Patients Race
Patients Ethnicity
Did patient have a history of an animal exposure
What type of animal was involved in the Exposure
What state did the animal exposure occur in
What country did the animal exposure occur in
What type of exposure occurred
Was the patient vaccinated for rabies prior to onset of symptoms
Did the patient have a recent (prior 12 months) history of travel?
What state did the patient travel to
What country did the patient travel to
When did the trip begin
When did the trip end
Date Symptoms began
Date patient hospitalized
Date patient died
What rabies virus variant was responsible for the infection

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
PHVS_City_USGS_GNIS
PHVS_State_FIPS_5-2
PHVS_Country_ISO_3166-1
PHVS_Occupation_CDC
PHVS_Sex_MFU
PHVS_RaceCategory_CDC_Unk
PHVS_EthnicityGroup_CDC_Unk
PHVS_YesNoUnknown_CDC
PHVS_AnimalSpecies_AnimalRabies
PHVS_State_FIPS_5-2
PHVS_Country_ISO_3166-1
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_State_FIPS_5-2
PHVS_Country_ISO_3166-1

PHVS_VirusVariantType_AnimalRabies

Label/Short Name
Long Term Care Facilty Resident
Culture Date
Bacterial Infection Syndrome
Sterile Specimen Type
Did Underlying Condition(s) exist?
Underlying Condition(s)
Oxacillin Zone Size
Oxacillin Interpretation
Antimicrobial Agent
Antimicrobial Susceptibility Test
Method
Antimicrobial Susceptibility Test
Result
Minimum Inhibitory Concentration
Range
Serotyping Results Available
Lab Result Coded Value
Serotype Method
23-Valent Pneumo Poly Vaccine
7-Valent Pneumo Conjugate Vaccine
13-Valent Pneumo Conjugate Vaccine
Vaccine Administered
Vaccine Manufacturer
Vaccine Lot Number
Vaccine Administered Date

Description
Does the patient reside in a long term care facility?
Date the first positive culture was obtained.
Types of infection(s) that are caused by the bacterial organism.
Sterile body site(s) from which the organism was isolated.
Did the subject have any pre-existing medical conditions before the start of the
illness/condition?
Listing of pre-existing conditions as related to the condition/illness
Oxacillin zone size for cases of Streptococcus pneumoniae
Oxacillin interpretation for cases of Streptococcus pneumoniae
Antimicrobial agent tested
Antimicrobial susceptibility testing method used
S/I/R/U result, indicating whether the microorganism is susceptible or not susceptible
(intermediate or resistant) to the antimicrobial being tested.
MIC (minimum inhibitory concentration) range.
Are serotyping results available for S pneumoniae isolate?
If Serotyping results are available for S pneumoniae isolate, please specify.
Serotyping Method Used
Has patient ≥2yrs received 23-valent pneumococcal polysaccharide vaccine
(Pneumovax)?
If less than eighteen years of age, did the patient receive 7-valent pneumococcal
conjugate vaccine (PCV7 or Prevnar)?
If less than eighteen years of age, did the patient receive 13-valent pneumococcal
conjugate vaccine (PCV13)?
The type of vaccine administered
Manufacturer of the vaccine
The vaccine lot number of the vaccine administered
The date that the vaccine was administered

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
PHVS_YesNoUnknown_CDC
PHVS_BacterialInfectionSyndrome_IPD
PHVS_SterileSpecimen_IPD
PHVS_YesNoUnknown_CDC
PHVS_UnderlyingConditions_IPD
PHVS_OxacillinInterpretation_IPD
PHVS_AntimicrobialAgent_IPD
PHVS_AntimicrobialSuceptiblilityTestMethod_IPD
PHVS_SusceptibilityResult_CDC

PHVS_YesNoUnknown_CDC
PHVS_SerotypeMethod_IPD
PHVS_SerotypeMethod_IPD
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_VaccinesAdministeredCVX_CDC_NIP
PHVS_ManufacturersOfVaccinesMVX_CDC_NIP

Label/Short Name
Diagnosis
Hospitalization for treatment
Admission date
Hospital name
Hospital address
Illness outcome
Nights away from home
Accommodation name
Accommodation address
Accommodation city
Accommodation state
Accommodation zip
Accommodation country
Accommodation room number
Arrival Date
Departure Date
Reported CDC
Whirlpool/Spa vicinity
Respiratory trherapy equipment use

Humidifier use
Water type
Healthcare setting visit/stay
Healthcare setting/facility
Exposure type
Facility name
Transplant center
Visit reason
HC facility city
HC facility state
Admission date
End date
Healthcare exposure
Assisted living facility exposure
AL facility type
AL exposure type
AL facility name
AL city
AL state

AL start date
AL end date
Urine Ag positive
Urine Ag collection date
Culture positive
Culture collection date
Culture site
Culture species
Culture serogroup
Ab titer
Acute titer
Acute collected
Convalescent titer
Convalescent collected
Ab titer other
Acute titer other
Acute collected other
Convalescent titer other
Convalescent collected other
Species other
Serogroup other
DFA/IHC positive
DFA/IHC collection date
DFA/IHV specimen site
Species other - DFA/IHC
Serogroup other - DFA/IHC
Nucleic Acid Assay - other
Nucleic Acid Assay collection date
Nucleic Acid Assay specimen site
Species other - nucleic acid assay
Serogroup other - nucleic acid assay
Whirlpool Spa, Location
Whirlpool Spa, Dates
Occupation
Interviewer’s Name
Interviewer’s Affiliation
Interviewer’s telephone number
Name of State Health Department
Official who reviewed this report
Title of State Health Department
Official who reviewed this report

Telephone Number of State Health
Department Official who reviewed
this report

Description
Disease caused by a Legionella species
Was patient hospitalized during treatment for legionellosis?
Date of admission to hospital
Name of hospital to which admitted
City and state of hospital
Outcome of illness
In the 10 days before onset, did the patient spend any nights away from home
(excluding healthcare settings)?
Name of lodging where patient stayed other than usual resident
Address of lodging away from home
City of lodging away from home
State of lodging away from home
Zipcode of lodging away from home
Country of lodging away from home
Room number at lodging where patient stayed other than usual resident
Date of stay arrival
Date of stay departure
If yes, was this case reported to CDC at [email protected]? 1
In the 10 days before onset, did the patient get in or spend time near a whirlpool spa
(i.e., hot tub)?
In the 10 days before onset, did the patient use a nebulizer, CPAP, BiPAP or any other
respiratory therapy equipment for the treatment of sleep apnea, COPD, asthma or for
any other reason?
If yes, does this device use a humidifier?
If yes, what type of water is used in the device? This is a multi-select field.
In the 10 days before onset, did the patient visit or stay in a healthcare setting (e.g.,
hospital, long term care/rehab/skilled nursing facility, clinic)?
Type of healthcare setting/facility
Type of exposure in HC setting/facility
Name of healthcare facility
Is this a transplant center?
Reason for visit to HC facility
City of HC facility
State of HC facility
Start date of HC facility admission/visit
End date of HC facility admission/visit
Was this case associated with a healthcare exposure?
In the 10 days before onset, did the patient visit or stay in an assisted living facility or
senior living facility?
Type of assisted living facility exposure
Type of assisted living facility
Name of AL facility
Name of city of AL facility
Name of state of AL facility

Start date of AL facility admission/visit
End date of AL facility admission/visit
Was the urine antigen positive?
Date urine antigen was collected
Was the culture positive?
Date culture was collected
Site of culture specimen
Species isolated from culture
Serogroup of species from culture
Was there a fourfold rise in Ab titer?
Initial Ab titer to L. pneumophila serogroup 1
Initial Ab titer specimen collection date
Convalescent Ab titer to L. pneumophila serogroup 1
Convalescent Ab specimen collection date
Was there a fourfold rise in Ab titer for other than L. pneumophila serogroup 1 or to
multiple species or serogroups of Legionella using pooled antigen?
Initial Ab titer to other than L. pneumophila serogroup 1
Initial Ab titer specimen collection date for species other than L. pneumophila
serogroup 1
Convalescent Ab titer to species other than L. pneumophila serogroup 1
Convalescent Ab specimen collection date for species other than L. pneumophila
serogroup 1
Species identified for other than L. pneumophila serogroup 1
Serogroup identified for other than L. pneumophila serogroup 1
Was the DFA or IHC positive?
Date specimen for DFA/IHC collected
Site of DFA/IHC specimen
Species identified by DFA/IHC for other than L. pneumophila serogroup 1
Serogroup identified by DFA/IHC for other than L. pneumophila serogroup 1
Was a nucleic acid assay (e.g., PCR) performed?
Date nucleic acid assay specimen collected
Site of nucleic acid assay specimen
Species identified by nucleic acid assay for other than L. pneumophila serogroup 1
Serogroup identified by nucleic acid assay for other than L. pneumophila serogroup 1
If Yes, describe where
If Yes, list dates
Subject’s Occupation
Interviewer’s Name
Interviewer’s Affiliation
Interviewer’s telephone number
Name of State Health Department Official who reviewed this report
Title of State Health Department Official who reviewed this report

Telephone Number of State Health Department Official who reviewed this report

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

Label/Short Name
Date First Submitted
State Case ID
Health care provider
Health care provider phone
Case Class Status Code
Subject Address State
Subject Address ZIP Code
Subject Address County
Subject’s Sex
Date of Birth

Age at case investigation
Age units at case investigation
Ethnic Group Code
Race Category
Symptomatic
Date symptom onset

Symptoms
Hospitalization?
Admission Date
Number of days
Outcome

Discharge Date
Deceased Date
Antibiotics prescribed
Antibiotics start date
Doxycycline
Penicillin
Other antibiotics
Reporting Lab Name
Date Sample Received at Lab
Date specimen collected
Specimen Type
Date of Acute Specimen Collection

Date of Convalscent Specimen
Collection
Resulted Test Name
Numeric Result
Result Units
Coded Result Value
Organism Name
Lab Result Text Value
Result Status
Specimens to CDC
Exposures
Animal contact
Livestock contact
Wildlife contact
Animal contact other
Animal contact location

Water contact

Water contact other
Water contact location
Contact Type
Occupational contact
Occupational contact other
Recreational contact
Recreational contact other
Avocational contact
Avocational contact other

Contact Type Other
Rodent infested housing
Rural residence
Hisotry of leptospirosis
Travel
Travel location
Rainfall
Flooding
Similar illness
Outbreak
Case Outbreak Name
Person Reporting to CDC - Name

Person Reporting to CDC - Phone
Number

Description
Date/time the notification was first sent to CDC. This value does not change after the
original notification.
States use this field to link NEDSS investigations back to their own state investigations.
Health care provider name
Health care provider phone number
Status of the case/event as suspect, probable, confirmed, or not a case per CSTE/CDC/
surveillance case definitions.
State of residence of the subject
ZIP Code of residence of the subject
County of residence of the subject
Subject’s current sex
Birth Date (mm/yyyy)

Subject age at time of case investigation
Subject age units at time of case investigation
Based on the self-identity of the subject as Hispanic or Latino
Field containing one or more codes that broadly refer to the subject’s race(s).
Was the case-patient symptomatic?
If Symptomatic was "Yes", provide the Date of Onset of symptoms
Select symptoms and signs reported or identified, from "Fever", "Myalgia",
"Headache", "Jaundice ", "Hepatitis", "Conjunctival suffusion", "Rash (Maculopapular
or petechial)", "Aseptic meningitis", "Gastrointestinal involvement", "Pulmonary
complications", "Cardiac involvement", "Renal insufficiency/failure ", "Hemorrhage",
"Other (specify)"
Was the case-patient hospitalized (at least overnight) for this Did the case-patient die?
Yes No Unk infection?
Subject’s first admission date to the hospital for the condition covered by the
investigation.
If hospitalized, number of days.
Clinical outcome of the patient ("Still hospitalized"; "Discharged"; "Died";"Other")

Subject's first discharge date from the hospital for the condition covered by the
investigation.
If the subject died from this illness or complications associated with this illness,
indicate the date of death
Were Antibiotics prescribed for this infection?
Date started taking antibiotics
Was doxycycline prescribed for this infection?
Was penicillin prescribed for this infection?
List other antibiotics prescribed for this infection
Name of Laboratory that reported test result.
Date Sample Received at Lab (accession date).
The date the specimen was collected.
Type of specimen collected ("Blood", "Urine", "Tissue", "CSF", "Other", "Unknown",
"Serum")
The date the acute specimen was collected.

The date the convalscent specimen was collected.
The lab test that was run on the specimen ("Microscopic Agglutination Test (MAT)",
"PCR", "Culture", "Immunofluorescence", "Darkfield microscopy", "ELISA (specify)",
"IHC", "Other, specify")
Results expressed as numeric value/quantitative result.
The unit of measure for numeric result value.
Coded qualitative result value (e.g., Positive, Negative).
The Organism (i.e., species and serovar) name as a test result. This element is used
when the result was reported as an organism.
Textual result value, used if result is neither numeric nor coded.
The Result Status is the degree of completion of the lab test.
Were specimens or isolates sent to CDC for testing?
Describe exposures to water, animals, or wet soil which the subject had in the 30 days
prior to illness onset
Select which animals the subject has had contact with in the 30 days prior to illness
onset, if any ("Farm livestock", "Wildlife", "Dogs", "Rodents", "Other", "No known
contact", "Unknown")
If the subject had contact with livestock, specify the animal(s)
If the subject had contact with wildlife, specify the animal(s)
If animal contact is "Other", describe the animal(s) with which the subject has had
contact
If the subject had contact with animals, specify the grographic location where the
contact occurred
Select which water sources the subject has had contact with in the 30 days prior to
illness onset, if any ("Standing fresh water (lake, pond, run-off)", "Flood water",
"River", "Wet soil", "Sewage","Water sports", "Other", "No known contact",
"Unknown")
If water contact is "Other", describe the water source(s) which the subject has had
contact
If the subject had contact with water, specify the grographic location where the
contact occurred
If subject had contact with animals, fresh water, or wet soil in the 30 days prior to
illness onset, describe the type of contact ("Occupational", "Recreational",
"Avocational", "Other")
If type of contact with animals or water is "Occupational", select the occupational
group ("Farmer (land)", "Farmer (animals)", "Fish worker", "Other", "Unknown")
If the occupational group through which the subject had contact with animals or water
is "Other", describe the occupation
If type of contact with animals or water is "Recreational", select the recreational
activity ("Swimming", "Boating", "Outdoor competition", "Camping/hiking", "Hunting",
"Other", "Unknown")
If the recreational activity through which the subject had contact with animals or water
is "Other", describe the recreational activity
If type of contact with animals or water is "Avocational", select the activity
("Gardening", "Pet-ownership", "Other", "Unknown")
If the Avocational activity through which the subject had contact with animals or water
is "Other", describe the avocational activity

If Contact Type is "Other", describe the type of contact with animals, wet soil, or
standing water
Did the patient stay in housing with evidence of rodents in the 30 days prior to illness
onset
Residence in rural area in the 30 days prior to illness onset
Does the subject have a hisotry of leptospirosis?
Did the subject travel out of the county, state, or country in the 30 days prior to
symptom onset?
If the travel is "Yes", provide location(s) of travel in the 30 days prior to symptom
onset
Was there heavy rainfall near the subjects place of residence, worksite, activities, or
travel in the 30 days prior to symptom onset?
Was there flooding near the subjects place of residence, worksite, activities, or travel
in the 30 days prior to symptom onset?
Did the patient have similar exposures as a contact diagnosed with leptospirosis in the
30 day period
Is this patient part of an outbreak?
A state-assigned name for an indentified outbreak.
Name of the person who is reporting the case to the CDC. This is the person that CDC
should contract in a state if there are questions regarding this case notification.
Phone Number of the person who is reporting the case to the CDC. This is the person
that CDC should contract in a state if there are questions regarding this case
notification.

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

PHVS_CaseClassStatus_NND
PHVS_State_FIPS_5-2
PHVS_County_FIPS_6-4

PHVS_AgeUnit_UCUM_NETSS
PHVS_EthnicityGroup_CDC_Unk
PHVS_RaceCategory_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_UnitsOfMeasure_CDC
PHVS_PosNegUnk_CDC
PHVS_Microorganism_CDC
PHVS_ObservationResultStatus_HL7_2x
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

Label/Short Name
Patient ID
Completed By
Date Completed
Case Year
Gender
State of Residence
Age
Date of Birth
State Epi ID
CDC/eFORS ID
Ethnicity
African American/Black
Asian
Native Hawaiian/Other Pacific
Islander
Native American
White
Unknown
Pregnancy
BloodNP
BloodNPDate
BloodNPLab
BloodNPIDNumber
CSFNP
CSFNPDate
CSFNPLab
CSFNPIDNumber
StoolNP
StoolNPDate
StoolNPLab
StoolNPIDNumber
OtherNP
OtherNPSpec
OtherNPDate
OtherNPLab
OtherNPIDNumber
OtherNP2
OtherNP2Spec
OtherNP2Date
NotherNP2Lab
OtherNP2IDNumber
BacteremiaNP

MeningitisNP
FebrilegastroenteritisNP
OtherIllnessNP
OtherNP specify
UnknownNP
HospitalizedNP
AdmitNP
DischargeNP
StillhospitalizedNP
OutcomeNP
BloodMotherAP
BloodMotherAPDate
BloodMotherAPLab
BloodMotherAPIDNumber
BloodNeonateAP
BloodNeonateAPDate
BloodNeonateAPLab
BloodNeonateAPIDNumber
CSFMotherAP
CSFMotherAPDate
CSFMotherAPLab
CSFMotherAPIDNumber
CSFNeonateAP
CSFNeonateAPDate
CSFNeonateAPLab
CSFNeonateAPIDNumber
StoolMotherAP
StoolMotherAPDate
StoolMotherAPLab
StoolMotherAPIDNumber
PlacentaAP
PlacentaAPDate
PlacentaAPLab
PlacentaAPIDNumber
AmnioticAP
AmnioticAPDate
AmnioticAPLab
AmnioticAPIDNumber
OtherAP

OtherAPSpec
OtherAPDate
OtherAPLab
OtherAPIDNumber
Other2AP
Other2APSpec
Other2APDate
Other2APLab
Other2APIDNumber
StillPregnantT1
StillPregT1Gest
StillPregT1Date
StillPregnantT2
StillPregnantT2Gest
StillPregnantT2Date
FetaldeathT1
FetalDeathT1Gest
FetalDeathT1Date
FetalDeathT2
FetalDeathT2Gest
FetalDeathT2Date
AbortionT1
AbortionT1Gest
AbortionT1Date
AbortionT2
AbortionT2Gest
AbortionT2Date
DeliveryT1
DeliveryT1Gest
DeliveryT1Date
DeliveryT2
DeliveryT2Gest
DeliveryT2Date
OtherT1AP
APOtherT1spec
APOtherT1Date

APOtherT1Gest
OtherT2AP
APOtherT2spec
APOtherT2Gest
APOtherT2Date
APBacteremiaMother
APMeningitisMother
APFebrileGastroMother
APAmnionitis
APFlulikeMother
APNoneMother
APOtherMother
ApOtherSpecMom
APUnknownMother
APBacteremiaT1
APMeningitisT1
APPneumoniaT1
APGranulomatosisT1
APNoneT1
APOtherT1
APOtherillT1spec
APUnknownT1
APBactermiaT2
APMeningitisT2
APPneumoniaT2
APGranulomatosisT2
APNoneT2
APOtherT2
APOtherillT2spec
APUnknownT2
APMotherHospitalized
APAdmitMother
APDischargeMother
APStillHospitalizedMother
APT1Hospitalized
APT1Admit
APT1Discharge
APT1StillHospitalized
APT2Hospitalized
APT2Admit
APT2Discharge
APT2StillHospitalized

APOutcomeMother
APOutcomeT1
APOutcomeT2
InterviewDate
InterviewInitials
Interviewee
Relationship
OtherSpec
Onset
HospitalizedBefore
HAdmit
HDischarge
Hname
StillHosp
NursingHomeBefore
Admitdate
DischargeDate
StillHosporNH
NHName
TravelState
StatesVisited
TravelInternat
Countries
DateDepart
DateReturn
Fever
Chills
Headache
MuscleAches
StiffNeck
Diarrhea
Vomiting
PretermLabor
Other
OtherSp
Other2
Other2Sp
TestDelivered
4weeksbefore
SpecCollection
GroceryPurchase
Grocery1

Grocery1Address
Grocery2
Grocery2Address
Grocery3
Grocery3Address
Grocery4
Grocery4Address
Grocery5
Grocery5Address
Grocery6
Grocery6Address
Grocery7
Grocery7Address
FarmersMarketPurchase
FarmersMarket1
FarmersMarket1Address
FarmersMarket2
FarmersMarket2Address
FarmersMarket3
FarmersMarket3Address
FarmersMarket4
FarmersMarket4Address
FarmersMarket5
FarmersMarket5Address
FarmersMarket6
FarmersMarket6Address
FarmersMarket7
FarmersMarket7Address
RestaurantPurchase
Restaurant1
Restaurant1Address
Restaurant1Date
Restaurant2
Restaurant2Address
Restaurant2Date
Restaurant3
Restaurant3Address

Restaurant3Date
Restaurant4
Restaurant4Address
Restaurant4Date
Restaurant5
Restaurant5Address
Restaurant5Date
Restaurant6
Restaurant6Address
Restaurant6Date
Restaurant7
Restaurant7Address
Restaurant7Date
OtherVenuePurchase

OtherVenue1
OtherVenue1Address
OtherVenue1Date
OtherVenue2
OtherVenue2Address
OtherVenue2Date
OtherVenue3
OtherVenue3Address
OtherVenue3Date
OtherVenue4
OtherVenue4Address
OtherVenue4Date
OtherVenue5
OtherVenue5Address
OtherVenue5Date
OtherVenue6
OtherVenue6Address
OtherVenue6Date
OtherVenue7
OtherVenue7Address
OtherVenue7Date
HamEat
HamOften
HamGrocery
HamDeli
HamRest
HamOther
Ham1
Ham2

Ham3
Ham4
HamBrand1
HamBrand2
HamBrand3
HamBrand4
HamDeliCounter
BolognaEat
BolognaOften
BolognaGrocery
BolognaDeli
BolognaRest
BolognaOther
Bologna1
Bologna2
Bologna3
Bologna4
BolognaBrand1
BolognaBrand2
BolognaBrand3
BolognaBrand4
BolognaDeliCounter
TurketEat
TurkeyOften
TurkeyGrocery
TurkeyDeli
TurkeyRest
TurkeyOther
Turkey1
Turkey2
Turkey3
Turkey4
TurkeyBrand1
TurkeyBrand2
TurkeyBrand3
TurkeyBrand4
TurkeyDeliCounter
OthturkeyEat
OthTurkeyOften
OthTurkeyGrocery
OthTurkeyDeli
OthTurkeyRest
OthTurkeyOther
OthTurkey1

OthTurkey2
OthTurkey3
OthTurkey4
OthTurkeyBrand1
OthTurkeyBrand2
OthTurkeyBrand3
OthTurkeyBrand4
OthTurkeyDeliCounter
ChickenDeliEat
ChickenDeliOften
ChickenDeliGrocery
ChickenDeliDeli
ChickenDeliRest
ChickenDeliOther
ChickenDeli1
ChickenDeli2
ChickenDeli3
ChickenDeli4
ChickenDeliBrand1
ChickenDeliBrand2
ChickenDeliBrand3
ChickenDeliBrand4
ChickenDeliDeliCounter
PastramiEat
PastramiOften
PastramiGrocery
PastramiDeli
PastramiRest
PastramiOther
Pastrami1
Pastrami2
Pastrami3
Pastrami4
PastramiBrand1
PastramiBrand2
PastramiBrand3
PastramiBrand4
PastramiDeliCounter
OtherDeliEat
OtherDeliSpec
OtherDeliOften
OtherDeliGrocery
OtherDeliDeli
OtherDeliRest
OtherDeliOther

OtherDeli1
OtherDeli2
OtherDeli3
OtherDeli4
OtherDeliBrand1
OtherDeliBrand2
OtherDeliBrand3
OtherDeliBrand4
OtherDeliCounter
PateEat
PateOften
PateGrocery
PateDeli
PateRest
PateOther
Pate1
Pate2
Pate3
Pate4
PateBrand1
PateBrand2
PateBrand3
PateBrand4
PateDeliConter
HotDogEat
HotDogOften
HotDogGrocery
HotDogDeli
HotDogRest
HotDogOther
HotDog1
HotDog2
HotDog3
HotDog4
HotDogBrand1
HotDogBrand2
HotDogBrand3
HotDogBrand4
HotDogDeliCounter
HotDogHeated
BrieAte
BrieOften
BrieGrocery
BrieDeli
BrieRest

BrieOther
Brie1
Brie2
Brie3
Brie4
BrieBrand1
BrieBrand2
BrieBrand3
BrieBrand4
BrieDeliCounter
FetaAte
FetaOften
FetaGrocery
FetaDeli
FetaRest
FetaOther
Feta1
Feta2
Feta3
Feta4
FetaBrand1
FetaBrand2
FetaBrand3
FetaBrand4
FetaDeliCounter
CamambAte
CamemOften
CamemGrocery
CamemDeli
CamemRest
CamemOther
Camem1
Camem2
Camem3
Camem4
Camembrand1
Camembrand2
Camembrand3
Camembrand4
Camemdelicounter
GoatAte
GoatOften
Goatgrocery
Goatdeli
Goatrest

Goatother
Goat1
Goat2
Goat3
Goat4
GoatBrand1
GoatBrand2
GoatBrand3
GoatBrand4
GoatDeliCounter
BlugorgAte
BlugorgOften
BlugorgGrocery
BlugorgDeli
BlugorgRest
BlugorgOther
Blugorg1
Blugorg2
Blugorg3
Blugorg4
BlugorgBrand1
BlugorgBrand2
BlugorgBrand3
BlugorgBrand4
BlugorgDeliCounter
MexAte
MexOften
MexGrocery
MexDeli
MexRest
MexOther
Mex1
Mex2
Mex3
Mex4
MexBrand1
MexBrand2
MexBrand3
MexBrand4
MexDeliCounter
FarmAte
FarmOften

FarmGrocery
FarmDeli
FarmRest
FarmOther
Farm1
Farm2
Farm3
Farm4
FarmBrand1
FarmBrand2
FarmBrand3
FarmBrand4
FarmDeliCounter
RawAte
RawOften
RawGrocery
RawDeli
RawRest
RawOther
Raw1
Raw2
Raw3
Raw4
RawBrand1
RawBrand2
RawBrand3
RawBrand4
RawDeliConter
OtherchAte
Otherchspec
OtherchOften
Otherchgrocery
Otherchdeli
OtherchRest
OtherchOther
Other1
Other2
Other3
Other4
OtherBrand1
OtherBrand2
OtherBrand3
OtherBrand4
OtherChDeliCounter

PotatoEat
PotatoOften
PotatoGrocery
PotatoDeli
PotatoRest
PotatoOther
Potato1
Potato2
Potato3
Potato4
PotatoBrand1
PotatoBrand2
PotatoBrand3
PotatoBrand4
PotatoDeliCounter
PastaEat
PastaOften
PastaGrocery
PastaDeli
PastaRest
PastaOther
Pasta1
Pasta2
Pasta3
Pasta4
PastaBrand1
PastaBrand2
PastaBrand3
PastaBrand4
PastaDeliCounter
TunaAte
TunaOften
TunaGrocery
TunaDeli
TunaRest
TunaOther
Tuna1
Tuna2
Tuna3
Tuna4
TunaBrand1
TunaBrand2
TunaBrand3
TunaBrand4
TunaDeliCounter

BeanAte
BeanOften
BeanGrocery
BeanDeli
BeanRest
BeanOther
Bean1
Bean2
Bean3
Bean4
BeanBrand1
BeanBrand2
BeanBrand3
BeanBrand4
BeanDeliCounter
HummusAte
HummusOften
HummusGrocery
HummusDeli
HummusRest
HummusOther
Hummus1
Hummus2
Hummus3
Hummus4
HummusBrand1
HummusBrand2
HummusBrand3
HummusBrand4
HummusDeliCounter
ColeAte
ColeOften
ColeGrocery
ColeDeli
ColeRest
ColeOther
Cole1
Cole2
Cole3
Cole4
ColeBrand1
ColeBrand2
ColeBrand3
ColeBrand4
ColeDeliCounter

SeafoodAte
SeafoodOften
SeafoodGrocery
SeafoodDeli
SeafoodRest
SeafoodOther
Seafood1
Seafood2
Seafood3
Seafood4
SeafoodBrand1
SeafoodBrand2
SeafoodBrand3
SeafoodBrand4
SeafoodDeliCounter
FruitAte
FruitOften
FruitGrocery
FruitDeli
FruitRest
FruitOther
Fruit1
Fruit2
Fruit3
Fruit4
FruitBrand1
FruitBrand2
FruitBrand3
FruitBrand4
FruitDeliCounter
OtherRTEAte
OtherRTESpecify
OtherRTEOften
OtherRTEGrocery
OtherRTEDeli
OtherRTERest
OtherRTEOther
OtherRTE1

OtherRTE2
OtherRTE3
OtherRTE4
OtherRTEBrand1
OtherRTEBrand2
OtherRTEBrand3
OtherRTEBrand4
OtherRTEDeliCounter
ShrimpAte
shrimpOften
ShrimpGrocery
ShrimpDeli
ShrimpRest
ShrimpOther
Shrimp1
Shrimp2
Shrimp3
Shrimp4
ShrimpBrand1
ShrimpBrand2
ShrimpBrand3
ShrimpBrand4
ShrimpDeliCounter
CrabAte
CrabOften
CrabGrocery
CrabDeli
CrabRest
CrabOther
Crab1
Crab2
Crab3
Crab4
CrabBrand1
CrabBrand2
CrabBrand3
CrabBrand4
CrabDeliCounter
SmokedAte
SmokedOften

SmokedGrocery
SmokedDeli
SmokedRest
SmokedOther
Smoked1
Smoked2
Smoked3
Smoked4
SmokedBrand1
SmokedBrand2
SmokedBrand3
SmokedBrand4
SmokedDeliCounter
HoneydewAte
HoneydewOften
HoneydewGrocery
HoneydewDeli
HoneydewRest
HoneydewOther
Honeydew1
Honeydew2
Honeydew3
Honeydew4
HonewdewBrand1
HonewdewBrand2
HonewdewBrand3
HonewdewBrand4
HoneydewDeliCounter
CantAte
CantOften
CantGrocery
CantDeli
CantRest
CantOther
Cant1
Cant2
Cant3
Cant4
CantBrand1
CantBrand2
CantBrand3
CantBrand4
CanteDeliCounter
WaterAte
WaterOften

WaterGrocery
WaterDeli
WaterRest
WaterOther
Water1
Water2
Water3
Water4
WaterBrand1
WaterBrand2
WaterBrand3
WaterBrand4
WaterDeliCounter
WmilkAte
WmilkOften
WmilkGrocery
WmilkDeli
WmilkRest
WmilkOther
Wmilk1
Wmilk2
Wmilk3
Wmilk4
WmilkBrand1
WmilkBrand2
WmilkBrand3
WmilkBrand4
WMilkRaw
2MilkAte
2MilkOften
2MilkGrocery
2MilkDeli
2MilkRest
2MilkOther
2Milk1
2Milk2
2Milk3
2Milk4
2MilkBrand1
2MilkBrand2
2MilkBrand3
2MilkBrand4
2MilkRaw
1MilkAte
1MilkOften

1MilkGrocery
1MilkDeli
1MilkRest
1MilkOther
1Milk1
1Milk2
1Milk3
1Milk4
1MilkBrand1
1MilkBrand2
1MilkBrand3
1MilkBrand4
1MilkRaw
SkimMilkAte
SkimMilkOften
SkimMilkGrocery
SkimMilkDeli
SkimMilkRest
SkimMilkOther
SkimMilk1
SkimMilk2
SkimMilk3
SkimMilk4
SkimMilkBrand1
SkimMilkBrand2
SkimMilkBrand3
SkimMilkBrand4
SkimMilkRaw
OtherMilkAte
OtherMilkSpec
OtherMilkOften
OtherMilkGrocery
OtherMilkDeli
OtherMilkRest
OtherMilkOther
OtherMilk1
OtherMilk2
OtherMilk3
OtherMilk4
OtherMilkBrand1
OtherMilkBrand2
OtherMilkBrand3
OtherMilkBrand4
OtherMilkRaw
ButterAte

ButterOften
ButterGrocery
ButterDeli
ButterRest
ButterOther
Butter1
Butter2
Butter3
Butter4
ButterBrand1
ButterBrand2
ButterBrand3
ButterBrand4
CreamAte
CreamOften
CreamGrocery
CreamDeli
CreamRest
CreamOther
Cream1
Cream2
Cream3
Cream4
CreamBrand1
CreamBrand2
CreamBrand3
CreamBrand4
IcecreamAte
IcecreamOften
IcecreamGrocery
IcecreamDli
IcecreamRest
IcecreamOther
Icecream1
Icecream2
Icecream3
Icecream4
IcecreamBrand1
IcecreamBrand2
IcecreamBrand3
IcecreamBrand4
SourcreamAte
SourcreamOften
SourcreamGrocery
SourcreamDeli

SourcreamRest
SourcreamOther
Sourcream1
Sourcream2
Sourcream3
Sourcream4
SourcreamBrand1
SourcreamBrand2
SourcreamBrand3
SourcreamBrand4
YogurtAte
YogurtOften
YogurtGrocery
YogurtDeli
YogurtRest
YogurtOther
Yogurt1
Yogurt2
Yogurt3
Yogurt4
YogurtBrand1
YogurtBrand2
YogurtBrand3
YogurtBrand4

Description
CDC assigned unique ID
Person completing LI form
Date LI form completed
Year of specimen collection
Gender
State of residence
Age of case-patient
Date of birth
State or local epi case ID
CDC/eFORS ID
Ethnicity
African American/Black
Asian
Native Hawaiian or Other Pacific Islander
Native American/Alaska Native
White
Unknown race
Is Listeria case associate with pregnancy
Blood specimen grew Listeria, non-pregnant case
Date blood specimen collected, non-pregnant case
Lab submitting blood specimen, non-pregnant case
State public health isolate ID number, blood, non-pregnant case
CSF speciment grew Listeria, non-pregnant case
Date CSF specimen collected, non-pregnant case
Lab submitting CSF specimen, non-pregnant case
State public health isolate ID number, CSF, non-pregnant case
Stool specimen grew Listeria, non-pregnant case
Date stool specimen collected, non-pregnant case
Lab submitting stool specimen, non-pregnant case
State public health isolate ID number, stool, non-pregnant case
Other specimen grew Listeria, non-pregnant case
Specify other specimen source, non-pregnant case
Date other specimen collected, non-pregnant case
Lab submitting other specimen, non-pregnant case
State public health isolate ID number, other specimen, non-pregnant case
Second "Other" specimen grew Listeria, non-pregnant case
Specify second "other" specimen source, non-pregnant case
Date second "other" specimen collected, non-pregnant case
Lab submitting second "other" specimen, non-pregnant case
State public health isolate ID number, second "other" specimen, non-pregnant case
Type of illness-Bacteremia/sepsis, non-pregnant case

Type of illness-Meningitis, non-pregnant case
Type of illness-Febrile gastroenteritis, non-pregnant case
Type of illness-Other, non-pregnant case
Specify other illness, non-pregnant case
Type of illness-Unknown, non-pregnant case
Was patient hospitalized for listeriosis, non-pregnant case
Hospital admit date, non-pregnant case
Hospital discharge date, non-pregnant case
Patient still hospitalized, non-pregnant case
Patient's outcome, non-pregnant case
Blood specimen from mother grew Listeria, pregnancy-associated case
Date blood specimen from mother collected, pregnancy-associated case
Lab submitting blood specimen from mother, pregnancy-associated case
State public health isolate ID number, blood specimen from mother, pregnancyassociated case
Blood specimen from neonate grew Listeria, pregnancy-associated case
Date blood specimen from neonate collected, pregnancy-associated case
Lab submitting blood specimen from neonate, pregnancy-associated case
State public health isolate ID number, blood specimen from neonate, pregnancyassociated case
CSF specimen from mother grew Listeria, pregnancy-associated case
Date CSF specimen from mother collected, pregnancy-associated case
Lab submitting CSF specimen from mother, pregnancy-associated case
State public health lab isolate ID number, CSF specimen from mother, pregnancyassociated
CSF specimen from neonate grew Listeria, pregnancy-associated case
Date CSF specimen from neonate collected, pregnancy-associated case
Lab submitting CSF specimen from neonate, pregnancy-associated case
State public health isolate ID number, CSF specimen from neonate, pregnancyassociated
Stool specimen from mother grew Listeria, pregnancy-associated case
Date stool specimen from mother collected, pregnancy-associated case
Lab submitting stool specimen from mother, pregnancy-associated case
State public health isolate ID number, stool specimen from mother, pregnancyassociated case
Placenta specimen grew Listeria, pregnancy-associated case
Date placenta specimen collected, pregnancy-associated case
Lab submitting placenta specimen, pregnancy-associated case
State public health lab isolate ID number, placenta specimen, pregnancy-associated
case
Amniotic fluid specimen grew Listeria, pregnancy-associated case
Date amniotic fluid collected, pregnancy-associated case
Lab submitting amniotic fluid specimen, pregnnacy-associated case
State public health lab isolate ID number, amniotic fluid specimen, pregnancyassociated case
Other specimen grew Listeria, pregnancy-associated case

Specify other specimen source, pregnancy-associated case
Date other specimen collected, pregnancy-associated case
Lab submitting other specimen, pregnancy-associated case
State public health lab isolate ID number, other specimen, pregnancy-associated case
Second "other" specimen grew Listeria, pregnancy-associated case
Specify second "other" specimen source, pregnancy-associated case
Date second "other" specimen collected, pregnancy-associated case
Lab submitting second "other" specimen, pregnancy-associated case
State public health lab isolate ID number, second "other" specimen, pregnancyassociated case
Outcome of pregnancy: Still pregnant (single gestation or twin 1), pregnancyassociated
If still pregnant, weeks of gestation (single gestation or twin 1), pregnancy-associated
If still pregnant, date (single gestation or twin 1), pregnancy-associated
Outcome of pregnancy: Still pregnant (twin 2), pregnancy-associated
If still pregnant, weeks of gestation (twin 2), pregnancy-associated
If still pregnant, date (twin 2), pregnancy-associated
Outcome of pregnancy: Fetal death (misscarriage or stillbirth; single gestation or twin
1), pregnancy-associated
If fetal death, weeks gestation (single gestation or twin 1), pregnancy-associated
If fetal death, date (single gestation or twin 1), pregnancy-associated
Outcome of pregnancy: Fetal death (misscarriage or stillbirth; twin 2), pregnancyassociated
If fetal death, weeks gestation (twin 2), pregnancy-associated
If fetal death, date (twin 2), pregnancy-associated
Outcome of pregnancy: Induced abortion (single gestation or twin 1), pregnancyassociated
If abortion, weeks gestation (single gestation or twin 1), pregnancy-associated
If abortion, date (single gestation or twin 1), pregnancy-associated
Outcome of pregnancy: Induced abortion (twin 2), pregnancy-associated
If abortion, weeks gestation (twin 2), pregnancy-associated
If abortion, date (twin 2), pregnancy-associated
Outcome of pregnancy: Delivery (live birth; single gestation or twin 1), pregnancyassociated
If delivery, weeks gestation (single gestation or twin 1), pregnancy-associated
If delivery, date (single gestation or twin 1), pregnancy-associated
Outcome of pregnancy: Delivery (live birth; twin 2), pregnancy-associated
If delivery, weeks gestation (twin 2), pregnancy-associated
If delivery, date (twin 2), pregnancy-associated
Outcome of pregnancy: Other (single gestation or twin 1), pregnancy-associated
If other pregnancy outcome, specify (single gestation or twin 1), pregnancy-associated
If other pregnancy outcome, date (single gestation or twin 1), pregnancy-associated

If other pregnancy outcome, weeks gestation (single gestation or twin 1), pregnancyassociated
Outcome of pregnancy: Other (twin 2), pregnancy-associated
If other pregnancy outcome, specify (twin 2), pregnancy-associated
If other pregnancy outcome, weeks gestation (twin 2), pregnancy-associated
If other pregnancy outcome, date (twin 2), pregnancy-associated
Type of illness in mother: Bacteremia/sepsis, pregnancy-associated
Type of illness in mother: Meningitis, pregnancy-associated
Type of illness in mother: Febrile gastroenteritis, pregnancy-associated
Type of illness in mother: Amnionitis, pregnancy-associated
Type of illness in mother: Non-specific "flu-like" illness, pregnancy-associated
Type of illness in mother: None, pregnancy-associated
Type of illness in mother: Other, pregnancy-associated
If other type of illness in mother, specify, pregnancy-associated
Type of illness in mother: Unknown, pregnancy-associated
Type of illness in neonate (twin 1): Bacteremia/sepsis, pregnancy-associated
Type of illness in neonate (twin 1): Meningitis, pregnancy-associated
Type of illness in neonate (twin 1): Pneumonia, pregnancy-associated
Type of illness in neonate (twin 1):Granulomatosis infantisepticum, pregnancyassociated
Type of illness in neonate (twin 1): None, pregnancy-associated
Type of illness in neonate (twin 1): Other, pregnancy-associated
If other type of illness in neonate (twin 1), specify, pregnancy-associated
Type of illness in neonate (twin 1): Unknown, pregnancy-associated
Type of illness in neonate (twin 2): Bacteremia/sepsis, pregnancy-associated
Type of illness in neonate (twin 2): Meningitis, pregnancy-associated
Type of illness in neonate (twin 2): Pneumonia, pregnancy-associated
Type of illness in neonate (twin 2): Granulomatosis infantisepticum, pregnancyassociated
Type of illness in neonate (twin 2): None, pregnancy-associated
Type of illness in neonate (twin 2): Other, pregnancy-associated
If other type of illness in neonate (twin 2), specify, pregnancy-associated
Type of illness in neonate (twin 2): Unknown, pregnancy-associated
Was mother hospitalized for listerosis? pregnancy-associated
Admit date, mother, pregnancy-associated
Discharge date, mother, pregnancy-associated
Mother still hospitalized, pregnancy-associated
Was neonate (twin 1) hospitalized for listeriosis? pregnancy-associated
Admit date, neonate (twin 1), pregnancy-associated
Discharge date, neonate (twin 1), pregnancy-associated
Neonate (twin 1) still hospitalized, pregnancy-associated
Was neonate 2 (twin 2) hospitalized for listeriosis? pregnancy-associated
Admit date, neonate (twin 2), pregnancy-associated
Discharge date, neonate (twin 2), pregnancy-associated
Neonate 2 (twin 2) still hospitalized, pregnancy-associated

Mother's outcome, pregnancy-associated
Neonate's (twin 1's) outcome, pregnancy-associated
Neonate 2's (twin 2's) outcome, pregnancy-associated
Date of interview
Initials of interviewer
Interviewee
If surrogate, relationship to patient
If other relationship to patient, specify
Onset of illness
Hospitalized (admitted to a hospital overnight) during 4 weeks before illness began
If hospitalized prior to onset, admit date
If hospitalized prior to onset, discharge date
Name of hospital admitted to in 4 weeks before illness began
Still hospitalized, if hospitalized in 4 weeks before illness began
Resident in nursing home or other long term care facility during 4 weeks before illness
began
Date admitted to nursing home (if resident in 4 weeks prior to onset)
Dicharge date from nursing home (if resident in 4 weeks prior to onset)
Still in nursing home, if in nursing home 4 weeks before illness began
Name of nursing home resident of in 4 weeks before illness began
During the 4 weeks before your illness, doid you travel to a state outside your state of
residence?
If traveled to state outside your state of residence in 4 weeks before illness, please list
states visited
During the 4 weeks before your illness, did you travel outside the US?
If traveled outside the US in 4 weeks before illness, what countries did you visit?
If traveled outside the US in 4 weeks before illness, what was your departure date?
If traveled outside the US in 4 weeks before illness, what date did you return?
Fever
Chills
Headache
Muscle Aches
Stiff Neck
Diarrhea (≥3 loose stools/day)
Vomiting
Preterm Labor
Other symptoms
Specify other symptoms
Other symptoms
Specify other symptoms
Date first positive Listeria isolate collected/delivery date (preg cases)
Four weeks before first positive Listeria isolate collected
Specimen collection date/delivery date (preg cases)
Did you eat food purchased from any grocery stores during the 4 week time period
Name of grocery store 1

Street address, city, county, state of grocery store 1
Name of grocery store 2
Street address, city, county, state of grocery store 2
Name of grocery store 3
Street address, city, county, state of grocery store 3
Name of grocery store 4
Street address, city, county, state of grocery store 4
Name of grocery store 5
Street address, city, county, state of grocery store 5
Name of grocery store 6
Street address, city, county, state of grocery store 6
Name of grocery store 7
Street address, city, county, state of grocery store 7
Did you eat food purchased from any delicatessens, small local markets, other small
shops, or farmers' markets during the 4 week period?
Name of delicatessen, small local market, other small shop, or farmers markets 1
Street address, city, county, state of delicatessen, small local market, other small shop,
or farmers market 1
Name of delicatessen, small local market, other small shop, or farmers markets 2
Street address, city, county, state of delicatessen, small local market, other small shop,
or farmers market 2
Name of delicatessen, small local market, other small shop, or farmers markets 3
Street address, city, county, state of delicatessen, small local market, other small shop,
or farmers market 3
Name of delicatessen, small local market, other small shop, or farmers markets 4
Street address, city, county, state of delicatessen, small local market, other small shop,
or farmers market 4
Name of delicatessen, small local market, other small shop, or farmers markets 5
Street address, city, county, state of delicatessen, small local market, other small shop,
or farmers market 5
Name of delicatessen, small local market, other small shop, or farmers markets 6
Street address, city, county, state of delicatessen, small local market, other small shop,
or farmers market 6
Name of delicatessen, small local market, other small shop, or farmers markets 7
Street address, city, county, state of delicatessen, small local market, other small shop,
or farmers market 7
Did you eat food from any restaurants, including sit-down, fast-food, and take-out
restaurants during the 4 week period?
Name of restaurant 1
Street address, city, county, state of restaurant 1
Dining date restaurant 1
Name of restaurant 2
Street address, city, county, state of restaurant 2
Dining date restaurant 2
Name of restaurant 3
Street address, city, county, state of restaurant 3

Dining date restaurant 3
Name of restaurant 4
Street address, city, county, state of restaurant 4
Dining date restaurant 4
Name of restaurant 5
Street address, city, county, state of restaurant 5
Dining date restaurant 5
Name of restaurant 6
Street address, city, county, state of restaurant 6
Dining date restaurant 6
Name of restaurant 7
Street address, city, county, state of restaurant 7
Dining date restaurant 7
Did you eat food purchased or obtained from any other venues, such as school
cafeteria, concession stands, street vendors, institutions (e.g., hospital food), local
farms, or private vendors during the 4 week period?
Name of other venue 1
Street address, city, county, state of venue 1
Dining date venue 1
Name of other venue 2
Street address, city, county, state of venue 2
Dining date venue 2
Name of other venue 3
Street address, city, county, state of venue 3
Dining date venue 3
Name of other venue 4
Street address, city, county, state of venue 4
Dining date venue 4
Name of other venue 5
Street address, city, county, state of venue 5
Dining date venue 5
Name of other venue 6
Street address, city, county, state of venue 6
Dining date venue 6
Name of other venue 7
Street address, city, county, state of venue 7
Dining date venue 7
In the 4 week period did you eat any ham deli, cold cut, or luncheon meat?
If ate ham, how often?
Was ham purchased at a grocery store?
Was ham purchased at a deli/small market ?
Was ham purchased at a restaurant?
Was ham purchased at an other venue?
Name of store/restaurant/venue where ham purchased 1
Name of store/restaurant/venue where ham purchased 2

Name of store/restaurant/venue where ham purchased 3
Name of store/restaurant/venue where ham purchased 4
Type or brand of ham purchased 1
Type or brand of ham purchased 2
Type or brand of ham purchased 3
Type or brand of ham purchased 4
Was ham purchased from a deli counter at any of the sites?
In the 4 week period did you eat any bologna deli, cold cut, or luncheon meat?
If ate bologna, how often?
Was bologna purchased at grocery store?
Was bologna purchased at a deli/small market?
Was bologna purchased at a restaurant?
Was bologna purchased at an other venue?
Name of store/restaurant/venue where bologna purchased 1
Name of store/restaurant/venue where bologna purchased 2
Name of store/restaurant/venue where bologna purchased 3
Name of store/restaurant/venue where bologna purchased 4
Type or brand of bologna 1
Type or brand of bologna 2
Type or brand of bologna 3
Type or brand of bologna 4
Was bologna purchased from a deli counter at any of the sites?
In the 4 week period did you eat any turkey deli, cold cut, or luncheon meat?
If ate turkey, how often?
Was turkey purchased at a grocery store?
Was turkey purchased at a deli/small market?
Was turkey purchased at a restaurant?
Was turkey purchased at an other venue?
Name of store/restaurant/venue where turkey purchased 1
Name of store/restaurant/venue where turkey purchased 2
Name of store/restaurant/venue where turkey purchased 3
Name of store/restaurant/venue where turkey purchased 4
Type or brand of turkey 1
Type or brand of turkey 2
Type or brand of turkey 3
Type or brand of turkey 4
Was turkey purchased from a deli counter at any of the sites?
In the 4 week period did you eat any other turkey deli, cold cut, or luncheon meat?
If ate other turkey, how often?
Was other turkey purchased at a grocery store?
Was other turkey purchased at a deli/small market?
Was other turkey purchased at a restaurant?
Was other turkey purchased at an other venue?
Name of store/restaurant/venue where other turkey purchased 1

Name of store/restaurant/venue where other turkey purchased 2
Name of store/restaurant/venue where other turkey purchased 3
Name of store/restaurant/venue where other turkey purchased 4
Type or brand of other turkey 1
Type or brand of other turkey 2
Type or brand of other turkey 3
Type or brand of other turkey 4
Was other turkey purchased from a deli counter at any of the sites?
In the 4 week period did you eat any chicken deli, cold cut, or luncheon meat?
If ate chicken, how often?
Was chicken purchased at a grocery store?
Was chicken purchased at a deli/small market?
Was chicken purchased at a restaurant?
Was chicken purchased at an other venue?
Name of store/restaurant/venue where chicken purchased 1
Name of store/restaurant/venue where chicken purchased 2
Name of store/restaurant/venue where chicken purchased 3
Name of store/restaurant/venue where chicken purchased 4
Type or brand of chicken 1
Type or brand of chicken 2
Type or brand of chicken 3
Type or brand of chicken 4
Was chicken purchased from a deli counter at any of the sites?
In the 4 week period did you eat any pastrami deli, cold cut, or luncheon meat?
If ate pastrami, how often?
Was pastrami purchased at a grocery store?
Was pastrami purchased at a deli/small market?
Was pastrami purchased at a restaurant?
Was pastrami purchased at an other venue?
Name of store/restaurant/venue where pastrami purchased 1
Name of store/restaurant/venue where pastrami purchased 2
Name of store/restaurant/venue where pastrami purchased 3
Name of store/restaurant/venue where pastrami purchased 4
Type or brand of pastrami 1
Type or brand of pastrami 2
Type or brand of pastrami 3
Type or brand of pastrami 4
Was pastrami purchased from a deli counter at any of the sites?
In the 4 week period did you eat any other deli, cold cut, or luncheon meat?
Specify other deli meat eaten
If at other deli meat, how often?
Was other deli meat purchased at a grocery store?
Was other deli meat purchased at a deli/small market?
Was other deli meat purchased at a restaurant?
Was other deli meat purchased at an other venue?

Name of store/restaurant/venue where other deli meat purchased 1
Name of store/restaurant/venue where other deli meat purchased 2
Name of store/restaurant/venue where other deli meat purchased 3
Name of store/restaurant/venue where other deli meat purchased 4
Type or brand of other deli meat 1
Type or brand of other deli meat 2
Type or brand of other deli meat 3
Type or brand of other deli meat 4
Was other deli meat purchased from a deli counter at any of the sites?
In the 4 week period did you eat any pate?
If yes, how often was pate eaten?
Was pate purchased at a grocery store?
Was pate purchased at a deli/small market?
Was pate purchased at a restaurant?
Was pate purchased at an other venue?
Name of store/restaurant/other venue where pate purchased 1
Name of store/restaurant/other venue where pate purchased 2
Name of store/restaurant/other venue where pate purchased 3
Name of store/restaurant/other venue where pate purchased 4
Type or brand of pate 1
Type or brand of pate 2
Type or brand of pate 3
Type or brand of pate 4
Was pate purchased from a deli counter at any of the sites?
In the 4 week period did you eat any hot dogs?
If yes, how often did you eat hot dogs?
Were hotdogs purchased at a grocery store?
Were hotdogs purchased at a deli/small market?
Were hotdogs purchased at a resutarant?
Were hotdogs purchased at an other venue?
Name of store/restaurant/other venue where hotdogs purchased 1
Name of store/restaurant/other venue where hotdogs purchased 2
Name of store/restaurant/other venue where hotdogs purchased 3
Name of store/restaurant/other venue where hotdogs purchased 4
Type or brand of hotdog 1
Type or brand of hotdog 2
Type or brand of hotdog 3
Type or brand of hotdog 4
Were hot dogs purchased from a deli counter at any of the sites?
Were hot dogs heated before consumption?
In the 4 week period, did you eat any brie?
If ate brie, how often?
Was brie purchased at a grocery store?
Was brie purchased at a deli/small market?
Was brie purchased at a restaurant?

Was brie purchased at an other venue?
Name of store/restaurant/other venue where brie purchased 1
Name of store/restaurant/other venue where brie purchased 2
Name of store/restaurant/other venue where brie purchased 3
Name of store/restaurant/other venue where brie purchased 4
Type or brand of brie 1
Type or brand of brie 2
Type or brand of brie 3
Type or brand of brie 4
Was brie purchased from a deli counter at any of the sites?
In the 4 week period, did you eat any feta?
If ate feta, how often?
Was feta purchased from a grocery store?
Was feta purchased from a deli/small market?
Was feta purchased from a restaurant?
Was feta purchased at an other venue?
Name of store/restaurant/other venue where feta purchased 1
Name of store/restaurant/other venue where feta purchased 2
Name of store/restaurant/other venue where feta purchased 3
Name of store/restaurant/other venue where feta purchased 4
Type or brand of feta 1
Type or brand of feta 2
Type or brand of feta 3
Type or brand of feta 4
Was feta purchased from a deli counter at any of the sites?
In the 4 week period did you eat any camembert?
If ate camembert, how often?
Was camembert purchased at a grocery store?
Was camembert purchased from a deli/small market?
Was camembert purchased from a restaurant?
Was camembert purchased from an other venue?
Name of store/restaurant/other venue where camembert purchased 1
Name of store/restaurant/other venue where camembert purchased 2
Name of store/restaurant/other venue where camembert purchased 3
Name of store/restaurant/other venue where camembert purchased 4
Type or brand of camembert 1
Type or brand of camembert 2
Type or brand of camembert 3
Type or brand of camembert 4
Was camembert purchased at a deli counter at any of these sites?
In the 4 weeks period did you eat any goat cheese?
If ate goat cheese, how often?
Was goat cheese purchased at a grocery store?
Was goat cheese purchased at a deli?
Was goat cheese purchased at a restaurant?

Was goat cheese purchased at an other venue?
Name of store/restaurant/other venue where goat cheese purchased 1
Name of store/restaurant/other venue where goat cheese purchased 2
Name of store/restaurant/other venue where goat cheese purchased 3
Name of store/restaurant/other venue where goat cheese purchased 4
Type or brand of goat cheese 1
Type or brand of goat cheese 2
Type or brand of goat cheese 3
Type or brand of goat cheese 4
Was goat cheese purchased at a deli counter at any of the sites?
In the 4 week period did you eat any blue or gorgonzola cheese?
If ate blue or gorgonzola cheese, how often?
Was blue or gorgonzola cheese purchased at a grocery store?
Was blue or gorgonzola cheese purchased at a deli?
Was blue or gorgonzola cheese purchased at a restaurant?
Was blue or gorgonzola cheese purchased at an other venue?
name of store/restaurant/other venue where blue or gorgonzola cheese purchased 1
name of store/restaurant/other venue where blue or gorgonzola cheese purchased 2
name of store/restaurant/other venue where blue or gorgonzola cheese purchased 3
name of store/restaurant/other venue where blue or gorgonzola cheese purchased 4
Type or brand of blue or gorgonzola cheese 1
Type or brand of blue or gorgonzola cheese 2
Type or brand of blue or gorgonzola cheese 3
Type or brand of blue or gorgonzola cheese 4
Was blue or gorgonzola cheese purchased at a deli counter at any of the sites?
In the 4 week period did you eat any Mexican-style cheese?
If ate Mexican-style cheese, how often?
Was Mexican-style cheese purchased at a grocery store?
Was Mexican-style cheese purchased at a deli/small market?
Was Mexican-style cheese purchased at a restaurant?
Was Mexican-style cheese purchased at an other venue?
Name of store/restaurant/other venue where Mexican-style cheese purchased 1
Name of store/restaurant/other venue where Mexican-style cheese purchased 2
Name of store/restaurant/other venue where Mexican-style cheese purchased 3
Name of store/restaurant/other venue where Mexican-style cheese purchased 4
Type or brand of Mexican-style cheese 1
Type or brand of Mexican-style cheese 2
Type or brand of Mexican-style cheese 3
Type or brand of Mexican-style cheese 4
Was Mexican-style cheese purchased at a deli counter at any of the sites?
In the 4 week period did you eat any Farmers cheese?
If ate Farmers cheese, how often?

Was Farmers cheese purchased at a grocery store?
Was Farmers cheese purchased at a deli/small market?
Was Farmers cheese purchased at a restaurant?
Was Farmers cheese purchased at an other venue?
Name of store/restaurant/other venue where Farmers cheese purchased 1
Name of store/restaurant/other venue where Farmers cheese purchased 2
Name of store/restaurant/other venue where Farmers cheese purchased 3
Name of store/restaurant/other venue where Farmers cheese purchased 4
Type or brand of Farmers cheese 1
Type or brand of Farmers cheese 2
Type or brand of Farmers cheese 3
Type or brand of Farmers cheese 4
Was Farmers cheese purchased at a deli counter at any of the sites?
In the 4 week period did you eat any raw cheese?
If ate raw cheese, how often?
Was raw cheese purchased at a grocery store?
Was raw cheese purchased at a deli/small market?
Was raw cheese purchased at a restaurant?
Was raw cheese purchased at an other venue?
Name of store/restaurant/other venue where raw cheese purchased 1
Name of store/restaurant/other venue where raw cheese purchased 2
Name of store/restaurant/other venue where raw cheese purchased 3
Name of store/restaurant/other venue where raw cheese purchased 4
Type or brand of raw cheese 1
Type or brand of raw cheese 2
Type or brand of raw cheese 3
Type or brand of raw cheese 4
Was raw cheese purchased at a deli counter at any of the sites?
In the 4 week period did you eat any other soft white cheese (not cream, cottage, or
ricotta)?
If ate other soft white cheese, specify
If ate other soft white cheese, how often?
Was other soft white cheese purchased at a grocery store?
Was other soft white cheese purchased at a deli/small market?
Was other soft white cheese purchased at a restaurant
Was other soft white cheese purchased at an other venue?
Name of store/restaurant/other venue where soft white cheese purchased 1
Name of store/restaurant/other venue where soft white cheese purchased 2
Name of store/restaurant/other venue where soft white cheese purchased 3
Name of store/restaurant/other venue where soft white cheese purchased 4
Type or brand of other soft white cheese 1
Type or brand of other soft white cheese 2
Type or brand of other soft white cheese 3
Type or brand of other soft white cheese 4
Was other soft white cheese purchased at a deli counter at any of the sites?

In the 4 weeks period did you eat any ready-to-eat, deli-style potato salad?
If ate potato salad, how often?
Was potato salad purchased from a grocery store?
Was potato salad purchased from a deli/small market?
Was potato salad purchased from a restaurant?
Was potato salad purchased at an other venue?
Name of store/restaurant/other venue where potato salad purchased 1
Name of store/restaurant/other venue where potato salad purchased 2
Name of store/restaurant/other venue where potato salad purchased 3
Name of store/restaurant/other venue where potato salad purchased 4
Type or brand of potato salad 1
Type or brand of potato salad 2
Type or brand of potato salad 3
Type or brand of potato salad 4
Was potato salad purchased from a deli counter at any of the sites?
In the 4 weeks period did you eat any ready-to-eat, deli-style pasta salad?
If at pasta salad, how often?
Was pasta salad purchased from a grocery store?
Was pasta salad purchased from a deli/small market?
Was pasta salad purchased from a restaurant?
Was pasta salad purchased from an other venue?
Name of store/restaurant/other venue where pasta salad purchased 1
Name of store/restaurant/other venue where pasta salad purchased 2
Name of store/restaurant/other venue where pasta salad purchased 3
Name of store/restaurant/other venue where pasta salad purchased 4
Type or brand of pasta salad 1
Type or brand of pasta salad 2
Type or brand of pasta salad 3
Type or brand of pasta salad 4
Was pasta salad purchased from a deli counter at any of the sites?
In the 4 weeks period did you eat any ready-to-eat, deli-style tuna salad?
If ate tuna salad, how often?
Was tuna salad purchase from a grocery store?
Was tuna salad purchase from a deli/small market?
Was tuna salad purchase from a restaurant?
Was tuna salad purchase from an other venue?
Name of store/restaurant/other venue where tuna salad purchased 1
Name of store/restaurant/other venue where tuna salad purchased 2
Name of store/restaurant/other venue where tuna salad purchased 3
Name of store/restaurant/other venue where tuna salad purchased 4
Type or brand tuna salad 1
Type or brand tuna salad 2
Type or brand tuna salad 3
Type or brand tuna salad 4
Was tuna salad purchased from a deli counter at any of the sites?

In the 4 weeks period did you eat any ready-to-eat, deli-style bean salad?
If ate bean salad, how often?
Was bean salad purchased from a grocery store?
Was bean salad purchased from a deli/small market?
Was bean salad purchased from a restaurant?
Was bean salad purchased from an other venue?
Name of store/restaurant/other venue where bean salad purchased 1
Name of store/restaurant/other venue where bean salad purchased 2
Name of store/restaurant/other venue where bean salad purchased 3
Name of store/restaurant/other venue where bean salad purchased 4
Type or brand of bean salad 1
Type or brand of bean salad 2
Type or brand of bean salad 3
Type or brand of bean salad 4
Was bean salad purchased from a deli counter at any of the sites?
In the 4 week period did you eat any ready-to-eat, deli-style hummus?
If at hummus, how often?
Was hummus purchased from a grocery store?
Was hummus purchased from a deli/small market?
Was hummus purchased from a restaurant?
Was hummus purchased from an other venue?
Name of store/restaurant/other venue where hummus purchased 1
Name of store/restaurant/other venue where hummus purchased 2
Name of store/restaurant/other venue where hummus purchased 3
Name of store/restaurant/other venue where hummus purchased 4
Type or brand of hummus 1
Type or brand of hummus 2
Type or brand of hummus 3
Type or brand of hummus 4
Was hummus purchased at a deli counter at any of the sites?
In the 4 week period did you eat any ready-to-eat, deli-style cole slaw?
If ate cole slaw, how often?
Was cole slaw purchased from a grocery store?
Was cole slaw purchased from a deli/small market?
Was cole slaw purchased from a restaurant?
Was cole slaw purchased from an other venue?
Name of store/restaurant/other venue where cole slaw purchased 1
Name of store/restaurant/other venue where cole slaw purchased 2
Name of store/restaurant/other venue where cole slaw purchased 3
Name of store/restaurant/other venue where cole slaw purchased 4
Type or brand of cole slaw 1
Type or brand of cole slaw 2
Type or brand of cole slaw 3
Type or brand of cole slaw 4
Was any cole slaw purchased from a deli counter at any of the sites?

In the 4 week period did you eat any ready-to-eat, deli-style seafood salad?
If ate seafood salad, how often?
Was seafood salad purchased from a grocery store?
Was seafood salad purchased from a deli/small market?
Was seafood salad purchased from a restaurant?
Was seafood salad purchased from an other venue?
Name of store/restaurant/other venue where seafood salad purchased 1
Name of store/restaurant/other venue where seafood salad purchased 2
Name of store/restaurant/other venue where seafood salad purchased 3
Name of store/restaurant/other venue where seafood salad purchased 4
Type or brand of seafood salad 1
Type or brand of seafood salad 2
Type or brand of seafood salad 3
Type or brand of seafood salad 4
Was any seafood salad purchased at a deli counter at any of the sites?
In the 4 week period did you eat any ready-to-eat, deli-style fruit salad?
If ate fruit salad, how often?
Was fruit salad purchased at a grocery store?
Was fruit salad purchased at a deli/small market?
Was fruit salad purchased at a restaurant?
Was fruit salad purchased at an other venue?
Name of store/restaurant/other venue where fruit salad purchased 1
Name of store/restaurant/other venue where fruit salad purchased 2
Name of store/restaurant/other venue where fruit salad purchased 3
Name of store/restaurant/other venue where fruit salad purchased 4
Type or brand fruit salad 1
Type or brand fruit salad 2
Type or brand fruit salad 3
Type or brand fruit salad 4
Was fruit salad purchased pre-cut?
In the 4 week period did you eat any other ready-to-eat meat, vegetable, or fruit salad
not made at home?
If ate other ready-to-eat meat, vegetable, or fruit salad not made at home, specify
If ate other ready-to-eat meat, vegetable, or fruit salad not made at home, how often?
Was other ready-to-eat meat, vegetable, or fruit salad not made at home purchased at
a grocery store?
Was other ready-to-eat meat, vegetable, or fruit salad not made at home purchased at
a deli/small market?
Was other ready-to-eat meat, vegetable, or fruit salad not made at home purchased at
a restaurant?
Was other ready-to-eat meat, vegetable, or fruit salad not made at home purchased at
an other venue?
Name of store/restaurant/other venue where other ready-to-eat meat, vegetable, or
fruit salad purchased 1

Name of store/restaurant/other venue where other ready-to-eat meat, vegetable, or
fruit salad purchased 2
Name of store/restaurant/other venue where other ready-to-eat meat, vegetable, or
fruit salad purchased 3
Name of store/restaurant/other venue where other ready-to-eat meat, vegetable, or
fruit salad purchased 4
Type or brand of other ready-to-eat meat, vegetable, or fruit salad 1
Type or brand of other ready-to-eat meat, vegetable, or fruit salad 2
Type or brand of other ready-to-eat meat, vegetable, or fruit salad 3
Type or brand of other ready-to-eat meat, vegetable, or fruit salad 4
Was other ready-to-eat meat, vegetable, or fruit salad purchased at a deli counter at
any of the sites?
In the 4 wek period did you eat any precooked shrimp?
If ate precooked shrimp, how often?
Was shrimp purchased at a grocery store?
Was shrimp purchased at a deli/small market?
Was shrimp purchased at a restaurant?
Was shrimp purchased at an other venue?
Name of store/restaurant/other venue where shrimp purchased 1
Name of store/restaurant/other venue where shrimp purchased 2
Name of store/restaurant/other venue where shrimp purchased 3
Name of store/restaurant/other venue where shrimp purchased 4
Type or brand of shrimp 1
Type or brand of shrimp 2
Type or brand of shrimp 3
Type or brand of shrimp 4
Was shrimp purchased at a deli counter at any of the sites?
In the 4 week period did you eat any precooked crab including imitation crab meat?
If ate precooked crab, how often?
Was crab purchased at a grocery store?
Was crab purchased at a deli/small market?
Was crab purchased at a restaurant?
Was crab purchased at an other venue?
Name of store/restaurant/other venue where crab purchased 1
Name of store/restaurant/other venue where crab purchased 2
Name of store/restaurant/other venue where crab purchased 3
Name of store/restaurant/other venue where crab purchased 4
Type or brand of crab 1
Type or brand of crab 2
Type or brand of crab 3
Type or brand of crab 4
Was crab purchased at a deli counter at any of the sites?
In the 4 week period did you eat any smoked or cured fish that was not from a can (e.g.
smoked salmon or lox)?
If ate smoked or cured fish, how often?

Was smoked or cured fish purchased at a grocery store?
Was smoked or cured fish purchased at a deli/small market?
Was smoked or cured fish purchased at a restaurant?
Was smoked or cured fish purchased at an other venue?
Name of store/restaurant/other venue where smoked or cured fish purchased 1
Name of store/restaurant/other venue where smoked or cured fish purchased 2
Name of store/restaurant/other venue where smoked or cured fish purchased 3
Name of store/restaurant/other venue where smoked or cured fish purchased 4
Type or brand smoked/cured fish 1
Type or brand smoked/cured fish 2
Type or brand smoked/cured fish 3
Type or brand smoked/cured fish 4
Was smoked or cured fish purchased at a deli counter at any of the sites?
In the 4 week period did you eat any honeydew?
If ate honeydew, how often?
Was honeydew purchased at a grocery store?
Was honeydew purchased at a deli/small market?
Was honeydew purchased at a restaurant?
Was honeydew purchased at an other venue?
Name of store/restaurant/other venue where honeydew purchased 1
Name of store/restaurant/other venue where honeydew purchased 2
Name of store/restaurant/other venue where honeydew purchased 3
Name of store/restaurant/other venue where honeydew purchased 4
Type or brand honeydew 1
Type or brand honeydew 2
Type or brand honeydew 3
Type or brand honeydew 4
Was the honeydew purchased pre-cut?
In the 4 week period did you eat any cantaloupe?
If ate cantaloupe, how often?
Was cantaloupe purchased at a grocery store?
Was cantaloupe purchased at a deli/small market?
Was cantaloupe purchased at a restaurant?
Was cantaloupe purchased at an other venue?
Name of store/restaurant/other venue where cantaloupe purchased 1
Name of store/restaurant/other venue where cantaloupe purchased 2
Name of store/restaurant/other venue where cantaloupe purchased 3
Name of store/restaurant/other venue where cantaloupe purchased 4
Type or brand of cantaloupe 1
Type or brand of cantaloupe 2
Type or brand of cantaloupe 3
Type or brand of cantaloupe 4
Was the cantaloupe purchased pre-cut?
In the 4 week period did you eat any watermelon?
If ate watermelon, how often?

Was watermelon purchased at a grocery store?
Was watermelon purchased at a deli/small market?
Was watermelon purchased at a restaurant?
Was watermelon purchased at an other venue?
Name of store/restaurant/other venue where watermelon purchased 1
Name of store/restaurant/other venue where watermelon purchased 2
Name of store/restaurant/other venue where watermelon purchased 3
Name of store/restaurant/other venue where watermelon purchased 4
Type or brand of watermelon 1
Type or brand of watermelon 2
Type or brand of watermelon 3
Type or brand of watermelon 4
Was the watermelon purchased pre-cut?
In the 4 week period did you eat any whole milk?
If ate whole milk, how often?
Was whole milk purchased at a grocery store?
Was whole milk purchased at a deli/small market?
Was whole milk purchased at a restaurant?
Was whole milk purchased at an other venue?
Name of store/restaurant/other venue where whole milk purchased 1
Name of store/restaurant/other venue where whole milk purchased 2
Name of store/restaurant/other venue where whole milk purchased 3
Name of store/restaurant/other venue where whole milk purchased 4
Type or brand whole milk 1
Type or brand whole milk 2
Type or brand whole milk 3
Type or brand whole milk 4
Was any whole milk unpasteurized (raw)?
In the 4 week period did you eat any 2% milk?
If ate 2% milk, how often?
Was 2% milk purchased at a grocery store?
Was 2% milk purchased at a deli/small market?
Was 2% milk purchased at a restaurant?
Was 2% milk purchased at an other venue?
Name of store/restaurant/other venue where 2% milk purchased 1
Name of store/restaurant/other venue where 2% milk purchased 2
Name of store/restaurant/other venue where 2% milk purchased 3
Name of store/restaurant/other venue where 2% milk purchased 4
Type or brand 2% milk 1
Type or brand 2% milk 2
Type or brand 2% milk 3
Type or brand 2% milk 4
Was any 2% milk unpasteurized (raw)?
In the 4 week period did you eat any 1% milk?
If ate 1% milk, how often?

Was 1% milk purchased at a grocery store?
Was 1% milk purchased at a deli/small market?
Was 1% milk purchased at a restaurant?
Was 1% milk purchased at an other venue?
Name of store/restaurant/other venue where 1% milk purchased 1
Name of store/restaurant/other venue where 1% milk purchased 2
Name of store/restaurant/other venue where 1% milk purchased 3
Name of store/restaurant/other venue where 1% milk purchased 4
Type or brand 1% milk 1
Type or brand 1% milk 2
Type or brand 1% milk 3
Type or brand 1% milk 4
Was any 1% milk unpasteurized (raw)?
In the 4 week period did you eat any skim milk?
If ate skim milk, how often?
Was skim milk purchased at a grocery store?
Was skim milk purchased at a deli/small market?
Was skim milk purchased at a restaurant?
Was skim milk purchased at an other venue?
Name of store/restaurant/other venue where skim milk purchased 1
Name of store/restaurant/other venue where skim milk purchased 2
Name of store/restaurant/other venue where skim milk purchased 3
Name of store/restaurant/other venue where skim milk purchased 4
Type or brand skim milk 1
Type or brand skim milk 2
Type or brand skim milk 3
Type or brand skim milk 4
Was any skim milk unpasteurized (raw)?
In the 4 week period did you eat any other milk?
If ate other milk, specify type of milk
If ate other milk, how often?
Was other milk purchased at a grocery store?
Was other milk purchased at a deli/small market?
Was other milk purchased at a restaurant?
Was other milk purchased at an other venue?
Name of store/restaurant/other venue where other milk purchased 1
Name of store/restaurant/other venue where other milk purchased 2
Name of store/restaurant/other venue where other milk purchased 3
Name of store/restaurant/other venue where other milk purchased 4
Type or brand other milk 1
Type or brand other milk 2
Type or brand other milk 3
Type or brand other milk 4
Was any other milk unpasteurized (raw)?
In the 4 week period did you eat any butter?

If ate butter, how often?
Was butter purchased at a grocery store?
Was butter purchased at a deli/small market?
Was butter purchased at a restaurant?
Was butter purchased at an other venue?
Name of store/restaurant/other venue where butter purchased 1
Name of store/restaurant/other venue where butter purchased 2
Name of store/restaurant/other venue where butter purchased 3
Name of store/restaurant/other venue where butter purchased 4
Type or brand butter 1
Type or brand butter 2
Type or brand butter 3
Type or brand butter 4
In the 4 week period did you eat any cream?
If ate cream, how often?
Was cream purchased at a grocery store?
Was cream purchased at a deli/small market?
Was cream purchased at a restaurant?
Was cream purchased at an other venue?
Name of store/restaurant/other venue where cream purchased 1
Name of store/restaurant/other venue where cream purchased 2
Name of store/restaurant/other venue where cream purchased 3
Name of store/restaurant/other venue where cream purchased 4
Type or brand cream 1
Type or brand cream 2
Type or brand cream 3
Type or brand cream 4
In the 4 week period did you eat any ice cream?
If ate ice cream, how often?
Was ice cream purchased at a grocery store?
Was ice cream purchased at a deli/small market?
Was ice cream purchased at a restaurant?
Was ice cream purchased at an other venue?
Name of store/restaurant/other venue where ice cream purchased 1
Name of store/restaurant/other venue where ice cream purchased 2
Name of store/restaurant/other venue where ice cream purchased 3
Name of store/restaurant/other venue where ice cream purchased 4
Type or brand ice cream 1
Type or brand ice cream 2
Type or brand ice cream 3
Type or brand ice cream 4
In the 4 week period did you eat any sour cream?
If ate sour cream, how often?
Was sour cream purchased at a grocery store?
Was sour cream purchased at a deli/small market?

Was sour cream purchased at a restaurant?
Was sour cream purchased at an other venue?
Name of store/restaurant/other venue where sour cream purchased 1
Name of store/restaurant/other venue where sour cream purchased 2
Name of store/restaurant/other venue where sour cream purchased 3
Name of store/restaurant/other venue where sour cream purchased 4
Type or brand sour cream 1
Type or brand sour cream 2
Type or brand sour cream 3
Type or brand sour cream 4
In the 4 week period did you eat any yogurt?
If ate yogurt, how often?
Was yogurt purchased at a grocery store?
Was yogurt purchased at a deli/small market?
Was yogurt purchased at a restaurant?
Was yogurt purchased at an other venue?
Name of store/restaurant/other venue where yogurt purchased 1
Name of store/restaurant/other venue where yogurt purchased 2
Name of store/restaurant/other venue where yogurt purchased 3
Name of store/restaurant/other venue where yogurt purchased 4
Type or brand yogurt 1
Type or brand yogurt 2
Type or brand yogurt 3
Type or brand yogurt 4

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

Label/Short Name
Erythema Migrans
Swelling
Bell’s Palsy or other cranial neuritis
Radiculoneuropathy
Lymphocytic meningitis
Encephalitis/Encephalomyelitis
2nd or 3rd degree atrioventricular
block
OtherSpeci
Results
EIA_IFA test type
EIA_IFA test result
Immunoblot result
IgM_21kDa
IgM_39kDa
IgM_41kDa
IgG_18kDa
IgG_21kDa
IgG_28kDa
IgG_30kDa
IgG_39kDa
IgG_41kDa
IgG_45kDa
IgG_58kDa
IgG_66kDa
IgG_93kDa

Description
Indicates whether the patient had erythema migrans (physician diagnosed EM at least
5 cm in diameter).
Indicates whether the patient had arthritis characterized by brief attacks of joint
swelling.
Indicates whether the patient had Bell's palsy or other cranial neuritis.
Indicates whether the patient had radiculoneuropathy.
Indicates whether the patient had lymphocytic meningitis.
Indicates whether the patient had encephalitis/encephalomyelitis.
Indicates whether the patient had 2nd or 3rd degree atrioventricular block.
Name of another laboratory test performed
Result of other specific laboratory tests performed
Type of EIA performed
Result of EIA
Result of immunblot
Immunoblot specific test result; linked to laboratory criteria
Immunoblot specific test result; linked to laboratory criteria
Immunoblot specific test result; linked to laboratory criteria
Immunoblot specific test result; linked to laboratory criteria
Immunoblot specific test result; linked to laboratory criteria
Immunoblot specific test result; linked to laboratory criteria
Immunoblot specific test result; linked to laboratory criteria
Immunoblot specific test result; linked to laboratory criteria
Immunoblot specific test result; linked to laboratory criteria
Immunoblot specific test result; linked to laboratory criteria
Immunoblot specific test result; linked to laboratory criteria
Immunoblot specific test result; linked to laboratory criteria
Immunoblot specific test result; linked to laboratory criteria

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
TEXT
P/N/E/ND/U
Whole cell antigen EIA/ELISA/ELFA; Defined antigen EIA/ELISA/ELFA;Antigen capture
EIA/ELISA/ELFA; IFA; Unknown; Other; not done
IgM positive only; IgG positive only; IgM and IgG positive; negative; unknown; not done
IgM positive only; IgG positive only; IgM and IgG positive; negative; unknown; not done
positive; negative; unknown; not done
positive; negative; unknown; not done
positive; negative; unknown; not done
positive; negative; unknown; not done
positive; negative; unknown; not done
positive; negative; unknown; not done
positive; negative; unknown; not done
positive; negative; unknown; not done
positive; negative; unknown; not done
positive; negative; unknown; not done
positive; negative; unknown; not done
positive; negative; unknown; not done
positive; negative; unknown; not done

Label/Short Name
Height
Height Units
Weight
Weight Units
Hospital Name
Hospital Record Number
Patient last name
Patient first name
Physician last name
Physician first name
Physician phone number
Laboratory Name
Laboratory Phone Number
Specimen(s) sent to CDC?
Specimen Type(s) sent to CDC
Description of other specimen type
Test Type
Organism Name
Description of other organism
Parasitemia Level Percentage
Subject Traveled or Lived Outside
U.S.
Subject Reside in U.S. prior to most
recent travel
Subject's Country of Residence prior
to most recent travel
Principal reason for Travel
Description of other reason for travel
International Destination(s) or
residence(s) #1
Date of return from travel #1
Duration of Stay #1
Duration of Stay Units #1
International Destination(s) or
residence(s) #2
Date of return from travel #2
Duration of Stay #2
Duration of Stay Units #2

International Destination(s) or
residence(s) #3
Date of return from travel #3
Duration of Stay #3
Duration of Stay Units #3
Was malaria chemoprophylaxis
taken?
Preventative Medication(s)
Description of other malaria
chemophophylaxis taken
Preventative Medication taken as
prescribed?
If doses were missed, what was the
reason?
Specific side effect that caused
missed doses
Description of the Other reason for
missing chemophophylaxis doses
History of malaria past 12 months
Date of previous malaria attack
Malaria species associated with
previous attack
Description of other malaria species
associated with previous attack
Received blood transfusion/organ
transplant
Blood transfusion/organ transplant
date
Complication(s)
Other complication(s)
Treatment Medication(s)
Other treatment medication(s)
Medications pre-treatment
Medications post-treatment
Malaria treatment taken as
prescribed
Symptoms resolved within 7 days
after treatment
Recurrence of symptoms during 4
weeks after treatment

Adverse events within 4 weeks after
starting treatment
Adverse Event #1 description
Adverse Event #1 relationship to
treatment
Adverse Event #1 time to onset
Adverse Event #1 fatal
Adverse Event #1 life-threatening
Adverse Event #1 other seriousness

Adverse Event #2 description
Adverse Event #2 relationship to
treatment
Adverse Event #2 time to onset
Adverse Event #2 fatal
Adverse Event #2 life-threatening
Adverse Event #2 other seriousness

Adverse Event #3 description
Adverse Event #3 relationship to
treatment
Adverse Event #3 time to onset
Adverse Event #3 fatal
Adverse Event #3 life-threatening
Adverse Event #3 other seriousness

Adverse Event #4 description
Adverse Event #4 relationship to
treatment
Adverse Event #4 time to onset
Adverse Event #4 fatal
Adverse Event #4 life-threatening
Adverse Event #4 other seriousness

Adverse Event #5 description
Adverse Event #5 relationship to
treatment
Adverse Event #5 time to onset
Adverse Event #5 fatal
Adverse Event #5 life-threatening
Adverse Event #5 other seriousness

Description
Subject's height
Subject's height units
Subject's weight
Subject's weight units
Name of hospital where case was admitted
Hospital Record Number, if subject was hospitalized
Patient's last name
Patient's first name
Last name of physician seen for this case
First name of physician seen for this case
Phone number of the physician seen for this case
Reporting Laboratory Name
Reporting Laboratory Phone Number
Was specimen sent to CDC for Malaria confirmation?
Type(s) of specimen sent to CDC.
Description of the other type of specimen sent to CDC
Epidemiologic interpretation of the type of test(s) performed for this case.
Species identified through testing.
Description of the other organism tested positive for
The estimated number of infected erythrocytes expressed as a percentage of the total
erythrocytes.
Has the subject traveled or lived outside the U.S. during the past two years?
Did the subject reside in the U.S. prior to most recent travel?
If the subject did not reside in the U.S. prior to most recent travel, what was the
country of residence?
If the subject did not reside in the U.S. prior to most recent travel, what was the
country of residence?
Description of the other reason for travel from/to the US
Destination(s) or residence(s) outside the U.S. during the past 2 years
Date the subject returned/arrived to the U.S. from an international destination or
residence.
Duration of stay in country outside the U.S.
Duration of stay units in country outside the U.S.
Destination(s) or residence(s) outside the U.S. during the past 2 years
Date the subject returned/arrived to the U.S. from an international destination or
residence.
Duration of stay in country outside the U.S.
Duration of stay units in country outside the U.S.

Destination(s) or residence(s) outside the U.S. during the past 2 years
Date the subject returned/arrived to the U.S. from an international destination or
residence.
Duration of stay in country outside the U.S.
Duration of stay units in country outside the U.S.
Was malaria chemoprophylaxis taken for prevention of malaria?
Listing of preventative medication(s) taken by the subject
Description of the other type of malaria chemoprophylaxis taken
Was all preventative medication taken as prescribed?
If doses of preventative medicine were missed, what was the primary reason?
Desciption of the side effect that was the reason for missing doses of malaria
chemoprophylaxis
Description of the other reason that resulted in missing doses of malaria
chemoprophylaxis
Does the subject have a previous history of malaria in the last 12 months (prior to this
report)?
Date of previous malaria attack
Malaria species associated with previous attack
Description of the other malaria species associated with the malaria attack in the past
12 months
Has the subject received a blood transfusion or organ transplant within the last 12
months?
If subject has received a blood transfusion/organ transplant within the last 12 months,
what was the date?
Listing of complications as related to this attack.
Description of the other clinical complications experienced during this episode/attack
of malaria
Listing of treatment medication the subject received for this attack.
Description of the other treatment medications received for this attack
List of all medications taken during the 2 weeks before starting treatment for malaria
List of all medications taken during the 4 weeks after starting treatment for malaria
Was the medicine for malaria treatment taken as prescribed?
Did all signs or symptoms of malaria resolve without any additional malaria treatment
within 7 days after starting treatment?
If signs and symptoms resolved within 7 days after starting treatment, did the patient
experience a recurrence of signs or symptoms of malaria during 4 weeks after starting
treatment?

Did the patient experience any adverse events within 4 weeks after receiving the
malaria treatment
Adverse Event description
Is it suspected a causal relationship between the treatment and the adverse event is at
least a reasonable possibility?
Time to onset since starting treatment
Was the adverse event fatal?
Was the adverse event life-threatening?
Was the adverse event serious in another way (i.e., significant disability/incapacity,
medically significant, requiring hospitalization or prolonging of existing
hospitalization)?
Adverse Event description
Is it suspected a causal relationship between the treatment and the adverse event is at
least a reasonable possibility?
Time to onset since starting treatment
Was the adverse event fatal?
Was the adverse event life-threatening?
Was the adverse event serious in another way (i.e., significant disability/incapacity,
medically significant, requiring hospitalization or prolonging of existing
hospitalization)?
Adverse Event description
Is it suspected a causal relationship between the treatment and the adverse event is at
least a reasonable possibility?
Time to onset since starting treatment
Was the adverse event fatal?
Was the adverse event life-threatening?
Was the adverse event serious in another way (i.e., significant disability/incapacity,
medically significant, requiring hospitalization or prolonging of existing
hospitalization)?
Adverse Event description
Is it suspected a causal relationship between the treatment and the adverse event is at
least a reasonable possibility?
Time to onset since starting treatment
Was the adverse event fatal?
Was the adverse event life-threatening?
Was the adverse event serious in another way (i.e., significant disability/incapacity,
medically significant, requiring hospitalization or prolonging of existing
hospitalization)?
Adverse Event description
Is it suspected a causal relationship between the treatment and the adverse event is at
least a reasonable possibility?
Time to onset since starting treatment
Was the adverse event fatal?
Was the adverse event life-threatening?
Was the adverse event serious in another way (i.e., significant disability/incapacity,
medically significant, requiring hospitalization or prolonging of existing
hospitalization)?

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
PHVS_HeightUnit_UCUM
PHVS_WeightUnit_UCUM
free text
free text
free text
free text
free text

PHVS_YesNoUnknown_CDC
PHVS_SpecimenType_Malaria
free text
PHVS_LabTestProcedure_Malaria
PHVS_Species_Malaria
free text

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_Country_ISO_3166-1
PHVS_TravelReason_Malaria
free text
PHVS_Country_ISO_3166-1

PHVS_AgeUnit_UCUM
PHVS_Country_ISO_3166-1

PHVS_AgeUnit_UCUM

PHVS_Country_ISO_3166-1

PHVS_AgeUnit_UCUM
PHVS_YesNoUnknown_CDC
PHVS_MedicationProphylaxis_Malaria
free text
PHVS_YesNoUnknown_CDC
PHVS_MedicationMissedReason_Malaria
free text
free text
PHVS_YesNoUnknown_CDC

PHVS_Species_Malaria
free text

PHVS_YesNoUnknown_CDC

PHVS_Complications_Malaria
free text
PHVS_MedicationTreatment_Malaria
free text
free text
free text
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
free text
checkbox
free text
checkbox
checkbox
checkbox

free text
checkbox
free text
checkbox
checkbox
checkbox

free text
checkbox
free text
checkbox
checkbox
checkbox

free text
checkbox
free text
checkbox
checkbox
checkbox

free text
checkbox
free text
checkbox
checkbox
checkbox

Label/Short Name
Did the subject have a rash?
Rash onset date
Rash Duration
Was the rash generalized?
Rash onset occur within 21 days of
entering USA
Did the subject have a fever?
Highest Measured Temperature
Temperature units
Date of fever onset
Cough
Coryza (runny nose)
Conjunctivitis
Otitis Media (Complication)
Diarrhea (Complication)
Pneumonia (Complication)
Encephalitis (Complication)
Thrombocytopenia (Complication)
Croup (Complication)
Hepatitis (Complication)
Other Complication
Specify Other Complication
Was laboratory testing done for
measles?
Test Type
Test Result
Sample Analyzed Date
Test Method
Date Collected
Specimen Source
Were the specimens sent to CDC for
genotyping (molecular typing)?
Specimen type sent to CDC for
genotyping
Date sent for genotyping
Was Measles virus genotype
sequenced?
Type of Genotype Sequence
Transmission Setting
Source of Infection

Were age and setting verified?

Is this case Epi-linked to another
confirmed or probable case?
Is this case linked to an international
imported case either directly or
within same chain of transmission?
International Destination(s) of recent
travel
Date of return from travel.
Did the subject ever receive a
disease-containing vaccine?
If no, reason subject did not receive a
disease-containing vaccine
Number of doses received BEFORE
first birthday
Number of doses received ON or
AFTER first birthday
Reason for vaccinating before first
(1st) birthday but not after
Reason subject received one dose ON
or AFTER first birthday, but never
received a second dose after the first
(1st) birthday
Total doses disease-containing
vaccine
Vaccine Administered
Vaccine Manufacturer
Vaccine Lot Number
Vaccine Administered Date
US Acquired

Description
Did the subject being reported in this investigation have a rash?
What was the onset date of the subject's rash?
How many days did the rash reported in this investigation last?
Was the rash generalized? (Occurring on more than one or two parts of the body?)
Did rash onset occur within 21 days of entering the USA, following any travel or living
outside the USA?
Did the subject have a fever? I.E., a measured temperature >2 degrees above normal
What was the subject's highest measured temperature during this illness?
The units of measure of the highest measured temperature. This would be either
Fahrenheit or Celsius.
Date of fever onset
Did the subject develop a cough during this illness?
Did the subject develop coryza (runny nose) during this illness?
Did the subject develop conjunctivitis during this illness?
Did the subject develop otitis media as a complication of this illness?
Did the subject develop diarrhea as a complication of this illness?
Did the subject develop pneumonia as a complication of this illness?
Did the subject develop encephalitis as a complication of this illness?
Did the subject develop thrombocytopenia as a complication of this illness?
Did the subject develop croup as a complication of this illness?
Did the subject develop hepatitis as a complication of this illness?
Did the subject develop other conditions as a complication of this illness?
Please specify the other complication the subject developed, during or as a result of
this illness.
Was laboratory testing done to confirm a diagnosis of measles?
Epidemiologic interpretation of the type of test(s) performed for this case
Epidemiologic interpretation of the results of the tests performed for this case.
The date the specimen/isolate was tested.
The technique or method used to perform the test and obtain the test results.
Date of specimen collection
The medium from which the specimen originated.
Were clinical specimens sent to CDC laboratories for genotyping (molecular typing)?
Specimen type sent to CDC for genotyping
The date the specimens were sent to the CDC laboratories for genotyping.
Identifies whether the Measles virus was genotype sequenced.
Identifies the genotype sequence of the Measles virus
What was the transmission setting where the measles was acquired?
What was the source of the measles infection?

Does the age of the case match or make sense for the transmission setting listed (i.e. A
subject aged 80 probably would not have a transmission setting of child day care
center.)?
Specify if this case is Epidemiologically-linked to another confirmed or probable case of
measles?
A "Yes" answer to this question denotes this case was infected by another subject who
acquired infection while outside of the U.S.

List any international destinations of recent travel
Date the subject returned from all travel
Did the subject ever receive a measles-containing vaccine?
If the subject did not receive a measles-containing vaccine, what was the reason?

The number of doses of measles-containing vaccine the subject received before their
first birthday.
The number of measles-containing vaccine doses the subject received on or after their
first birthday.
If the subject was vaccinated with measles-containing vaccine BEFORE the first
birthday, but did not receive a vaccine dose after their first birthday, state the reason.
If the subject received one dose of measles-containing vaccine ON or AFTER their first
birthday, but did not receive a second dose after the first birthday, what was the
reason?
Total doses measles-containing vaccine
The type of vaccine administered
Manufacturer of the vaccine
The vaccine lot number of the vaccine administered
The date that the vaccine was administered
Sub-classification of disease or condition acquired in the US

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_TemperatureUnit_UCUM

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_LabTestProcedure_Measles
PHVS_LabTestInterpretation_VPD
PHVS_LabTestMethod_CDC
PHVS_SpecimenSource_Measles
PHVS_YesNoUnknown_CDC
PHVS_SpecimenSource_Measles

PHVS_YesNoUnknown_CDC
PHVS_Genotype_Measles
PHVS_TransmissionSetting_NND

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_Country_ISO_3166-1

PHVS_YesNoUnknown_CDC
PHVS_VaccineNotGivenReasons_CDC

PHVS_VaccineNotGivenReasons_CDC

PHVS_VaccineNotGivenReasons_CDC

PHVS_VaccinesAdministeredCVX_CDC_NIP
PHVS_ManufacturersOfVaccinesMVX_CDC_NIP

PHVS_CaseClassificationExposureSource_NND

Label/Short Name
State Case ID
Date of First Report to CDC
Notification Result Status
Condition Code
Case Class Status Code
MMWR Week
MMWR Year
Reporting State
Reporting County
National Reporting Jurisdiction
Reporting Source Type Code
Reporting Source ZIP Code
Date First Reported PHD
Person Reporting to CDC - Name

Person Reporting to CDC - Phone
Number
Person Reporting to CDC - Title

Person Reporting to CDC - Affiliation

Subject Address County
Subject Address State
Age units at case investigation
Country of Birth
Time in U.S.
Date entered U.S.
Travel or Live Outside U.S.
Country of Exposure or Country
Where Disease was Acquired
Note: use exposure or acquired
consistently across variables
Subject’s Sex
Race Category

Ethnic Group Code
Country of Usual Residence

Earliest Date Reported to County
Earliest Date Reported to State
Diagnosis Date
Date of Onset of symptoms
Date sample collected
Date test performed
Type of test utilized to identify case
Test Result
Hospitalized
Did patient expire?
Current antimicrobial Treatment
Date current antimicrobial Treatment
Diabetes
Chronic renal disease
Chronic lung disease
Liver disease or chronic alcohol
abuse
Thalassemia
Non HIV-related immune suppression
Military service
Military service Date
Laboratory exposure
Laboratory exposure Date
Contact with soil or water in
melioidosis-endemic areas
Contact with soil or water in
melioidosis-endemic areas service
Date
Contact with someone with the same
disease
Were you at any recent mass
gathering?

Description
States use this field to link NEDSS investigations back to their own state investigations.
Date the case was first reported to the CDC
Status of the notification.
Condition or event that constitutes the reason the notification is being sent
Status of the case/event as suspect, probable, confirmed, or not a case per CSTE/CDC/
surveillance case definitions.
MMWR Week for which case information is to be counted for MMWR publication.
MMWR Year (YYYY) for which case information is to be counted for MMWR
publication.
State reporting the notification.
County reporting the notification.
National jurisdiction reporting the notification to CDC.
Type of facility or provider associated with the source of information sent to Public
Health.
ZIP Code of the reporting source for this case.
Earliest date the case was reported to the public health department whether at the
local, county, or state public health level.
Name of the person who is reporting the case to the CDC. This is the person that CDC
should contract in a state if there are questions regarding this case notification.
Phone Number of the person who is reporting the case to the CDC. This is the person
that CDC should contract in a state if there are questions regarding this case
notification.
Job title / description of the person reporting the case to the CDC. This is the person
that CDC should contract in a state if there are questions regarding this case
notification.
Affiliated Facility of the person reporting the case to the CDC. This is the person that
CDC should contract in a state if there are questions regarding this case notification.
County of residence of the subject
State of residence of the subject
Subject age units at time of case investigation
Country of Birth
Length of time this subject has been living in the U.S. (if born out of the U.S.
Date entered U.S. in YYYYMM format (if born out of the U.S.)
Did the subject travel or live outside the U.S.A.?
Indicates the country in which the disease was potentially acquired.

Subject’s current sex
Field containing one or more codes that broadly refer to the subject’s race(s).

Based on the self-identity of the subject as Hispanic or Latino
Where does the person usually* live (defined as their residence)
*For the definition of ‘usual residence’ refer to CSTE position statement # 11-SI-04
titled “Revised Guidelines for Determining Residency for Disease Reporting” at
http://www.cste.org/ps2011/11-SI-04.pdf .
Earliest date reported to county public health system
Earliest date reported to state public health system
Earliest date of diagnosis (clinical or laboratory) of condition being reported to public
health system
Date of the beginning of the illness. Reported date of the onset of symptoms of the
condition being reported to the public health system
Provide date test was performed in YYYYMM format
Provide date test was performed in YYYYMM format
Indicate the type of test performed to confirm case
Epidemiologic interpretation of the results of the tests performed for this case
Indicate whether subject was or is currently hospitalized due to this illness
Indicate whether subject died of this illness
Indicate all antimicrobial drugs used to treat subject
Indicate the date antimicrobial treatment started
Does subject have diabetes?
Does subject have chronic renal disease?
Does subject have chronic lung disease?
Does subject have liver disease or chronic alcohol abuse?
Does subject have thalassemia?
Does subject have non HIV-related immune suppression?
Has subject ever served overseas in in the military?
If yes, date of service in YYYYMM format.
Was subject ever exposed to burkolderia through lab work?
If yes, date of exposure in YYYYMM format.
Has subject ever been in contact with soil or water in melioidosis-endemic areas?
If yes, date of contact in YYYYMM format.

Did subject have contact with someone diagnosed with melioidosis?
Was subject present at any recent mass gathering?

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

PHVS_ResultStatus_NETSS
PHVS_NotifiableEvent_Disease_Condition_CDC_NNDSS
PHVS_CaseClassStatus_NND

PHVS_State_FIPS_5-2
PHVS_County_FIPS_6-4
PHVS_NationalReportingJurisdiction_NND
PHVS_ReportingSourceType_NND

PHVS_County_FIPS_6-4
PHVS_State_FIPS_5-2
PHVS_AgeUnit_UCUM_NETSS
PHVS_CountryofBirth_CDC

PHVS_YesNoUnknown_CDC
PHVS_Country_ISO_3166-1

PHVS_Sex_MFU
PHVS_RaceCategory_CDC

PHVS_EthnicityGroup_CDC_Unk
PHVS_CountryofBirth_CDC

PHVS_LabTestInterpretation_melioidosis
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_MedicationTreatment_Melioidosis
PHVS_MedicationTreatment_Date_Melioidosis
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

Label/Short Name
Did the subject have a fever?
Date of Fever Onset
Highest Measured Temperature
Temperature Units
Parotitis (opposite second (2nd)
molars)? (Symptom)
Unilateral or Bilateral Parotitis
(Symptom)
Jaw Pain (Symptom)
Salivary Gland Swelling Onset Date
Salivary Gland Swelling Duration
Salivary Gland Swelling Duration
Units
Submandibular Swelling (Symptom)
Sublingual Swelling (Symptom)
Import Status
International Destination(s) of recent
travel
Date of return from travel
Encephalitis (Complication)
Meningitis (Complication)
Deafness (Complication)
Type of Deafness
Orchitis (Complication)
Other Complication
Specify Other Complication
Was laboratory testing done for
mumps?
Test Type
Test Result
Numeric Test Result
Numeric Test Result Units
Sample Analyzed Date
Test Method
Date Collected
Specimen Source
Were the specimens sent to CDC for
genotyping (molecular typing)?
Date sent for genotyping

Transmission Setting
Were Age and Setting Verified?

Source of Infection
Case Class by Source
Is this Case Epi-Linked to Another
Confirmed or Probable Case?
Did the subject ever receive a
disease-containing vaccine?
If no, reason subject did not receive a
disease-containing vaccine
Number of doses received ON or
AFTER first birthday
Vaccine History Comments
Vaccine Administered
Vaccine Manufacturer
Vaccine Lot Number
Vaccine Administered Date
US Acquired
Length of time in the US
Length of Time in the U.S. units
Patient Address City
Case Investigation Status Code
Detection Method
Transmission Setting, Other
Laboratory Confirmed
Specimen sent to CDC
Type of testing at CDC
Type of testing at CDC, other
Date specimen sent to CDC
VPD Lab Message Patient Identifier
VPD Lab Message Observation
Identifier
VPD Lab Message Observation Value
Other Lab Test
Performing Laboratory Type
Other (Performing Laboratory Type)
Date of last dose prior to illness
onset
Vaccination doses prior to onset

Vaccinated per ACIP
recommendations
Reason not vaccinated per ACIP
recommendations
Reason not vaccinated per ACIP,
Other
Vaccine Administered Product Type,
Other
Vaccine Product Manufacturer,
Other
NDC Brand Name/Bar Code
information
Vaccination Record ID
Reason immunizaton not given,
regardless of the schedule used

Description
Did the subject have a measured temperature greater than two degrees above
normal?
Date of fever onset
What was the subject's highest measured temperature during this illness?
The units of measure of the highest measured temperature. This would be either
Fahrenheit or Celsius.
Did the subject have parotitis as a symptom of this illness?
Indicates if the parotitis is unilateral or bilateral
Did the subject have jaw pain as a symptom of this illness?
Date of subject's salivary gland swelling (including parotitis) onset.
The length of time that the subject exhibited swelling of the salivary gland.
The length of time units that the subject exhibited swelling of the salivary gland
Did the subject have submandibular swelling as a symptom of this illness?
Did the subject have sublingual swelling as a symptom of this illness?
Did symptom onset occur within 12-25 days of entering the U.S., following any travel
or living outside the U.S.?
List any international destinations of recent travel
Date the subject returned from all travel
Did the subject develop encephalitis as a complication of this illness?
Did the subject develop meningitis as a complication of this illness?
Did the subject become deaf as a complication of this illness?
Was the type of deafness permanent or temporary?
Did the subject develop orchitis as a complication of this illness?
Did the subject develop an other condition as a complication of this illness?
Please specify the other complication the subject developed, during or as a result of
this illness.
Was laboratory testing done to confirm a diagnosis of mumps?
Epidemiologic interpretation of the type of test(s) performed for this case.
Epidemiologic interpretation of the results of the tests performed for this case
Numeric quantitative result of the test(s) performed for this case
Numeric quantitative result unit of the test(s) performed for this case
The date the specimen/isolate was tested.
The technique or method used to perform the test and obtain the test results.
Date of specimen collection
The medium from which the specimen originated
Were clinical specimens sent to CDC laboratories for genotyping (molecular typing)?
The date the specimens were sent to the CDC laboratories for genotyping

What was the transmission setting where the mumps was acquired?
Does the age of the case match or make sense for the transmission setting listed (e.g.,
a subject aged 80 probably would not have a transmission setting of child day care
center)?
What was the source of the mumps infection?
If this is a case aquired in the U.S., how should the case be classified by source?
Specify if this case is Epidemiologically-linked to another confirmed or probable case of
mumps?
Did the subject ever receive a mumps-containing vaccine?
Specifies reason the subject did not receive a mumps-containing vaccine

The number of measles-containing vaccine doses the subject received on or after their
first birthday
Comments about the subject's vaccination history.
The type of vaccine administered.
Manufacturer of the vaccine.
The vaccine lot number of the vaccine administered.
The date that the vaccine was administered.
Sub-classification of disease or condition acquired in the US
Length of time in the US, from NBS MM
Length of time in the US Units
Patient address city, from NBS MM
Case Investigation Status Code, from NBS MM
Detection Method, from NBS MM
If Other, Specify Transmission Setting
Was the case laboratory confirmed?
Was a specimen sent to CDC for testing?
What type of testing was done at CDC for this subject?
If other, specify testing done at CDC
Date specimen sent to CDC
VPD Lab Message Patient Identifier
VPD Lab Message Observation Identifier
VPD Lab Message Observation Value
If other, specify lab test
Performing laboratory type
If other, specify performing laboratory type
Date of last disease-containing vaccination dose prior to illness onset
Number of disease-containing vaccination doses prior to illness onset

Was subject vaccinated as recommended by ACIP?
Reason subject not vaccinated as recommended by ACIP
If other, specify reason not vaccinated per ACIP
If other, specify type of vaccine administered
If other, specify vaccine manufacturer
NDC from the vaccine's bar code. With the NDC code, vaccine brand name and
manufacturer can be obtained.
Vaccination Record ID, from NBS MM
Reason subject was not vaccinated, regardless of the immunization schedule used

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
PHVS_YesNoUnknown_CDC

PHVS_TemperatureUnit_UCUM
PHVS_YesNoUnknown_CDC
PHVS_ParotitisLaterality_Mumps
PHVS_YesNoUnknown_CDC

PHVS_AgeUnit_UCUM
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_Country_ISO_3166-1

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_DeafnessType_Mumps
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_LabTestProcedure_Mumps
PHVS_LabTestInterpretation_VPD
PHVS_UnitsOfMeasure_CDC
PHVS_LabTestMethods_CDC
PHVS_SpecimenSource_Mumps
PHVS_YesNoUnknown_CDC

PHVS_TransmissionSetting_NND
PHVS_YesNoUnknown_CDC

PHVS_CaseClassificationExposureSource_NND
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_VaccineNotGivenReasons_CDC

PHVS_VaccinesAdministeredCVX_CDC_NIP
PHVS_ManufacturersOfVaccinesMVX_CDC_NIP

PHVS_CaseClassificationExposureSource_NND

Label/Short Name
DAYCARE
FACNAME
NURSHOME
NHNAME
SYNDRM
SPECSYN
SPECIES
OTHBUG1
STERSITE
OTHSTER
DATE
NONSTER
UNDERCOND
COND
OTHMALIG
OTHORGAN
OTHILL
OTHOTHSPC
Specify Internal Body Site
Other Prior Illness 2
Other Prior Illness 3
Other Nonsterile Site
INSURANCE
INSURANCEOTH
WEIGHTLB
WEIGHTOZ
WEIGHTKG
HEIGHTFT
HEIGHTIN
HEIGHTCM
WEIGHTUNK
HEIGHTUNK
SEROGROUP
OTHSERO
COLLEGE
CASEID
OTHSTRST
OTHID
SCHOOLYR
STUDTYPE
HOUSE
OTHHOUSE

SCHOOLNM
POLYVAC
SECCASE
SECCASETY
OTHSECCASE
NMSULFRES
NMRIFARES
DIAGDATE
PCRSOURCE
IHCSPEC1
IHCSPEC2
IHCSPEC3
MENGVAC

Description
If <6 years of age, is the patient in daycare?
Name of the daycare facility.
Does the patient reside in a nursing home or other chronic care facility?
Name of the nursing home or chronic care facility.
Types of infection that are caused by the organism. This is a multi-select field.
Other infection that is caused by the organism.
Bacterial species that was isolated from any normally sterile site.
Other bacterial species that was isolated from any normally sterile site.
Sterile sites from which the organism was isolated. This is a multi-select field.
Other sterile site from which the organism was isolated.
Date the first positive culture was obtained. (This is considered diagnosis date.)
Nonsterile sites from which the organism was isolated. This is a multi-select field.
Did the patient have any underlying conditions?
Underlying conditions that the subject has. This is a multi-select field.
Other malignancy that the subject had as an underlying condition.
Detail of the organ transplant that the subject had as an underlying condition.
Other prior illness that the subject had as an underlying condition.
Another Bacterial Species not listed in the Other Bacterial Species drop-down list.
Internal Body Site where the organism was located.
Other prior illness that the subject had as an underlying condition.
Other prior illness that the subject had as an underlying condition.
Other nonsterile site from which the organism was isolated.
Patient's type of insurance (multi-selection).
Patient's other type of insurance.
Weight of the patient in pounds.
Weight of the patient in ounces.
Weight of the patient in kilograms.
Height of the patient in feet.
Height of the patient in inches.
Height of the patient in centimeters.
Indicator that the weight of the patient is unknown.
Indicator that the height of the patient is unknown.
Serogroup of the culture.
Other serogroup of the culture.
Is patient currently attending college? This question is only applicable if the patient is
15-24 years of age.
How was the case identified?
Other sterile site from which species was isolated.
Other case identification method.
Patient's year in college. (freshman, sophomore, etc.)
Patient's status in college as defined by the university.
Patient's current living situation.
Other housing option.

Full name of the college or university the patient is currently attending.
Has patient received the polysaccharide meningococcal vaccine?
Is this case of Neiserria meningitidis a secondary case?
Type of secondary contact for a case of Neisseria meningitidis.
Other field available if the secondary case type selected is other.
Neisseria meningitidis resistance to Sulfa.
Neisseria meningitidis resistance to Rifampin.
Date the sample was collected for diagnostic testing if a culture was not done.
Specifies the PCR source for how the case was identified.
Specifies the first IHC specimen.
Specifies the second IHC specimen.
Specifies the third IHC specimen.
Specifies whether the patient has received a meningococcal vaccine.

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
TBD
TBD
TBD
TBD

TBD
PHVS_YesNoUnknown_CDC
TBD

TBD

TBD

PHVS_TrueFalse_CDC
PHVS_TrueFalse_CDC
TBD
PHVS_YesNoUnknown_CDC
TBD

TBD
TBD
TBD

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
TBD
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
TBD

Label/Short Name
Fever >38°C (100.4°F)
Feverish but temp not taken
Cough
Headache
Seizures
Sore throat
Conjunctivitis
Shortness of breath
Diarrhea
Other
Vaccinated
Vaccination date
Vaccine type
Antiviral medications
Date initiated oseltamivir
Date discontinued oseltamivir
Oseltamivir dosage
Zanamivir
Date initiated zanamivir
Date discontinued zanamivir
Rimantidine
Date initiated rimantidine
Date discontinued rimantidine
Amantidine
Date initiated amantidine
Date discontinued amantidine
Other antivial (specify)
Dateintiated other
Date discontinued other
Leukopenia
Lymphopenia
Thrombocytopenia
Underlying medical conditions
Compromised immune function
Compromised immune function
specified
Mechanical ventilation
Chest x-ray/CAT
Pneumonia
ARDS
Death
Test 1 Specimen Type

Test 1 Date collected
Test 1 type
Test 2 Specimen Type
Test 2 Date collected
Test 2 type
Specimens to CDC
Epi Risk - Travel
Country/Arrival/Departure
Case close contact
Animal touch

Animal exposure

Environmental exposure

Raw/Undercooked animals

Animal contact
Laboratory sample handling
HC setting
Household illness contact
Household death contact
Porcine exposure
Porcine contact
Epidemiological link with labconfirmed or probable case

Description
Did/does the patient have a fever (specify max temp)?
Did/does the patient have a fever but temperature not taken?
Was cough a symptom?
Did/does the patient have a headache?
Did/does the patient have seizures?
Did/does the patient have a sore throat?
Did/does the patient have conjunctivitis?
Did/does the patient have shortness of breath?
Did/does the patient have shortness of breath?
Did/does the patient have any other symptoms (specify)?
Was the patient vaccinated against human influenza in the past year?
If yes, date of vaccination
If yes, type of vaccine received?
Did the patient receive antiviral medications?
What was the date that oseltamivir was intiated?
What was the date that oseltamivir was discontinued?
What was the dosage of oseltamivir?
What was the date that zanamivir was intiated?
What was the date that zanamivir was discontinued?
What was the dosage of zanamivir?
What was the date that rimantidine was intiated?
What was the date that rimantidine was discontinued?
What was the dosage of rimantidine?
What was the date that amantidine was intiated?
What was the date that amantidine was discontinued?
What was the dosage of amantidine?
What was the date that an other antiviral was intiated?
What was the date that an other antiviral was discontinued?
What was the dosage of an other antiviral?
Was leukopenia a lab finding?
Was lymphopenia a lab finding?
Was thrombocytopenia a lab finding?
Does the patient have any underlying medical conditions?
Does the patient have compromised immune function such as HIV infection, cancer,
chronic corticosteroid therapy, diabetes, or organ transplant recipient?
If yes, specify function.
Did the patient require mechanical ventilation?
Did the patient have a chest x-ray or CAT scan performed?
If abnormal, was there evidence of pneumonia?
If abnormal, did the patient have acute respiratory distress syndrome??
Did the patient die a s a result of this illness?
What was the specimen type for diagnostic test 1?

Date of collection of specimen for test 1?
What is the test type for diagnostic test 1?
What was the specimen type for diagnostic test 2?
Date of collection of specimen for test 2?
What is the test type for diagnostic test 2?
Indicate when and what type of specimens (including sera) were sent to CDC
In the 10 days prior to illness onset, did the patient travel?
If yes, fill in the arrival and departure dates for all countries visited.
Did the patient have close contact with a person who is a suspected, probable,, or
confirmed novel human influenza A case?
Did the patient touch animals or their remains in an area where influenza infection in
animals or novel influenza in humans has been suspected or confirmed in the last
month?
Was the patient exposed to animal remains in an area where influenza infection in
animals or novel influenza in humans has been suspected or confirmed in the last
month?
Was the patient exposed to environments contaminated by animal feces in an area
where influenza infection in animals or novel influenza in humans has been suspected
or confirmed in the last month?
Did the patient consume raw or undercooked animals in an area where influenza
infection in animals or novel influenza in humans has been suspected or confirmed in
the last month?
Did the patient have any animal contact (specify)?
Did the patient handle samples suspected of containing influenza virus in a laboratory
or other setting?
Does the patient work in a healthcare facility or setting?
Did the patient visit or stay in the same household with anyone with pneumonia or
severe influenza-like illness?
Did the patient visit or stay in the same household with anyone who died following
thevisit?
Did the patient visit an agricultural event, farm, petting zoo, or place where pigs live or
were exhibited in the last month?
Did the patient have direct contact with pigs at an agricultural event, farm, petting zoo,
or place where pigs were exhibited in the last month?
If this patient has a diagnosis of novel influenza A virus infection that has not been
serologically confirmed, is there an epidemiologic link between this patient and a labconfirmed or probable novel influenza A case?

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

Label/Short Name
Autopsy
Cardiac/respiratory arrest
Location of death
Hospital Admission Date
Pathology specimens to CDC
Lab ID for pathology specimen
Isolates/original clinical material
Lab ID for isolates/clinical specimen
Staph aureus isolates
Lab ID for isolates
Commercial Rapid Diagnostic Test
Rapid test result
Rapid test specimen collection date
Viral Culture
Viral culture result
Viral culture specimen collection date
Fluorescent Antibody (IFA or DFA)
IFA/DFA result
IFA/DFA specimen collection date
Enzyme Immunoassay
EIA result
EIA collection date
RT-PCR test
RT-PCR result
RT-PCR specimen collection date
IHC test
IHC result
IHC specimen collection date
Bacterial Culture
Specimen Type
Collection Date
Bacterial Culture Results
Bacterial culture species isolated
Other Respiratory Specimen/ Nonsterile site
Other respiratory specimen site
Other respiratory specimen site
Other respiratory specimen
collection date

Other respiratory specimen result
Bacterial species cultured
Autopsy Specimen
Autopsy Specimen Results
Mechanical Ventilation
Complications
Type complications
Existing Medical Conditions
Medical conditions before acute
illness
Medications and/or Therapies
Medications received before illness
Medications received after illness
Influenza Vaccine
Vaccine before illness
1 Dose <14 days
1 Dose >14 days
2 Dose <14 days
2 Dose >14 days
Previous Seasonal Vaccine
1 Dose Seasonal

2 Dose Seasonal
1 Dose AT Least

Description
Was an autopsy performed on the patient?
Did the patient experience cardiac/respiratory arrest outside the hospital?
What was the location of the patient's death?
If patient's death occurrred in a hospital, what was the date of admission?
Were pathology specimens sent to CDC's Infectious Diseases Pathology Branch?
Provide the lab ID number(if known) for pathology specimen(s) sent to CDC.
Were influenza isolates or original clinical material sent to CDC Influenza Division?
Provide the lab ID number(if known) for isolates/clinical specimen(s) sent to CDC.
Were staph aureus isolates sent to CDC's Healthcare Quality Promotion?
Provide the lab ID number(if known) for isolate(s) sent to CDC.
Indicate if commercial rapid test used.
What is the result of the rapid test?
What is the specimen collection date for the rapid test?
Indicate if viral culture used.
What is the result of the viral culture?
What is the specimen collection date for the viral culture?
Indicate if fluorescent antibody test used.
What is the result of the IFA/DFA?
What is the specimen collection date for the IFA/DFA?
Indicate if enzyme immunoassay used.
What is the result of the EIA?
What is the specimen collection date for the EIA?
Indicate if an RT-PCR test was used.
What is the result of the RT-PCR?
What is the specimen collection date for the RT-PCR?
Indicate if an immunohistochemistry test was used.
What is the result of the IHC?
What is the specimen collection date for the IHC?
Was a specimen collected for bacterial culture from a normally sterile site?
What was the specimen type obtained for the bacterial culture? This is a multi-select
field.
What was the collection date for the bacterial culture?
What was the result of the bacterial culture?
If bacterial culture positive, check the organism cultured. This is a multi-select field.
Were other respiratory specimens from non-sterile site(s) collected for bacterial
culture (e.g., sputum, ET tube aspirate)?
If yes, indicate the site from which the specimen was obtained. This is a multi-select
field.
If yes, indicate the date collected of the specimen.
If yes, indicate the date collected of the specimen.

If yes, indicate the result for the specimen culture.
If positve, what was the organism cultured?
Was a specimen (e.g., fixed lung tissue) collected from an autopsy for bacterial
pathogen testing?
If autopsy specimen was taken, what were the results (indicate in the comments
section)?
Was the patient placed on mechanical ventilation?
Did complications occur during the acute illness?
If yes, check all complications that occurred during the acute illness. This is a multiselect field.
Did the child have any medical conditions that existed before the start of the acute
illness?
If yes,check all medical conditions that exised before the start of the acute illness. This
is a multi-select field
Was the patient receiving any of the listed therapies prior to illness onset?
Check all medications/therapies patient was receiving before the acute illness. This is a
multi-select field.
Did the patient receive any of the following after illness onset? This is a multi-select
field.
Did the patient receive any seasonal influenza vaccine during the current season
(before illness)?
If yes, specify the seasonal vaccine received before illness onset.
If yes, did patient receive 1 dose of vaccine <14 days prior to illness onset (date given)?
If yes, did patient receive1 dose of vaccine ≥14 days prior to illness onset (date given)?
If yes, did patient receive vaccines <14 days prior to illness onset (dates given)?
If yes, did patient receive 2 doses of vaccines ≥14 days prior to illness onset (dates
given)?
Did the patient receive any seasonal influenza vaccine in previous seasons?
If yes, and patient was between 6 months and ≤8 years of age at the time of death, was
the 2009-2010 influenza season the first time the patient received seasonal influenza
vaccine?
If yes, did patient receive 2 doses of seasonal influenza vaccine during the 2009-2010
influenza season?
If the patient was between 6 months and ≤8 years of age at the time of death, did they
receive at least 1 dose of 2009 influenza A (H1N1) vaccine during the previous season?

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

Label/Short Name
Did the patient have a cough?
Cough Onset Date
Paroxysmal Cough
Whoop
Post-tussive Vomiting
Apnea
Date of Final Interview
Did the patient have a cough at final
interview?
Total Cough Duration
Result of chest X-ray for pneumonia
Did the patient have generalized or
focal seizures due to pertussis?
Did the patient have acute
encephalopathy due to pertussis?
Were antibiotics given?
Antibiotic Name
Antibiotic Start Date
Number of days antibiotic actually
taken.
Second antibiotic patient received?
Date second antibiotic started
Number of days second antibiotic
actually taken
Was laboratory testing done for
pertussis?
Test Type
Test Result
Date Collected
Did the subject ever receive a
disease-containing vaccine?
Vaccine Administered
Vaccine Manufacturer
Vaccine Lot Number
Vaccine Administered Date
Is this case epi-linked to a laboratoryconfirmed case?
Is this case part of a cluster or
outbreak (e.g. total is 2 or more
cases)?
Transmission Setting

Was there documented transmission
from this case of pertussis to a new
setting? (not in household)
Number of contacts of this case
recommended to receive antibiotic
prophylaxis
Age of person contracted patient
contracted pertussis from
Age Type
Setting where patient contracted
pertussis
Specify In which setting was pertussis
acquired.
Specify In which setting was there
secondary spread
Name Of Contacts
Birth Date of contacts
Contact Relationship to Subject
Case?
Contact Case ID
Cough Onset Date(If Present
Number of PCVs*
Date of Last PCV
Parent’s Name (If Applicable)
Parent’s Phone # (If Applicable)
Cyanosis
Treatment Drug, Other
Case patient a healthcare worker
Mother’s age at infant’s birth
Gestational age in weeks
Birth Weight
Birth Weight Units
Did mother receive Tdap?
Timing of mother's Tdap
administration
Date of mother's Tdap
administration
One or more suspected sources?
Number of suspected sources?
Suspected source sex
Suspected source relationship to
case (other)
Patient Address City

Case Investigation Status Code
Detection Method
Age at cough onset
Age type at cough onset
Laboratory Confirmed
Specimen sent to CDC
Type of testing at CDC
Type of testing at CDC, Other
Date specimen sent to CDC
VPD Lab Message Patient Identifier
VPD Lab Message Observation
Identifier
VPD Lab Message Observation Value
Test Type, Other
Specimen ID Placer Assigned
Identifier
Specimen ID Filler Assigned
Identifier
Performing Laboratory Type
Performing Laboratory Type, Other
Numeric Test Result
Numeric Test Result Units
Vaccinated per ACIP
recommendations
Reason not vaccinated per ACIP
recommendations
Reason not vaccinated per ACIP,
Other
Vaccine Administered Product Type,
Other
NDC Brand Name/Bar Code
information
Vaccine Product Manufacturer,
Other
Vaccine Lot Expiration Date
Vaccination Record ID
Reason immunizaton not given,
regardless of the schedule used
Other transmission setting
Setting of further spread
Suspected source relation to case
Estimated cough onset date of
suspected source

Description
Did the patient's illness include the symptom of cough?
Cough onset date
Did the patient's illness include the symptom of paroxysmal cough?
Did the patient's illness include the symptom of whoop?
Did the patient's illness include the symptom of post-tussive vomiting?
Did the patient's illness include the symptom of apnea?
Date of the patient's final interview
Was there a cough at the patient's final interview?
What was the duration (in days) of the patient's cough?
Result of chest x-ray for pneumonia
Did the patient have generalized or focal seizures due to pertussis?
Did the patient have acute encephalopathy due to pertussis?
Were antibiotics given to the patient?
What antibiotic did the patient receive?
Date the patient first started taking the antibiotic
Number of days the patient actually took the antibiotic referenced
If Other, please specify antibiotic
Date second antibiotic started
Number of days second antibiotic actually taken
Was laboratory testing done for pertussis?
Epidemiologic interpretation of the type of test(s) performed for this case
Epidemiologic interpretation of the results of the tests performed for this case.
Date of specimen collection
Did the patient ever receive a pertussis-containing vaccine?
The type of vaccine administered.
Manufacturer of the vaccine.
The vaccine lot number of the vaccine administered.
The date that the vaccine was administered.
Is this case epi-linked to a laboratory-confirmed case?
Is this case part of a cluster or outbreak (e.g. total is 2 or more cases)?

Transmission setting (Where did this case acquire pertussis?)

Was there documented transmission (outside of the household) for transmission from
this case?

Number of contacts of this case recommended to receive antibiotic prophylaxis

Age of the person from whom this patient contracted pertussis
Age Type
Transmission setting (Where did this patient acquire pertussis?)
setting in which pertussis was acquired
In which setting was there secondary spread
Name Of Contacts
Birth Date of contacts
Relationship of contact
Case
Unique case identifier of the contact. This would be the same as INV168 (Case Local
ID)
Cough Onset Date(If Present
Number of PCVs*
Date of Last PCV
Parent’s Name (If Applicable)
Parent’s Phone # (If Applicable)
Did patient have cyanosis during his/her illness?
If other, specify antibiotic used
Was case patient healthcare personnel (HCP) (at illness onset)?
Mother’s age at infant’s birth (used only if patient under 12 months old)
Gestational age (if case-patient < 1 year of age at illness onset)
Infant’s birth weight (used only if patient under 12 months old)
Infant’s birth weight units
Did mother receive Tdap (if case-patient < 1 year of age at illness onset)?
If mother received Tdap, when was it administered?
If mother received Tdap, what date was it administered? *(if available)
Was there one or more suspected sources of infection? (from NBS MM)
Number of suspected sources? (from NBS MM)
Suspected source sex (from NBS MM)
Suspected source relationship to case (other)
Patient Address City, from NBS MM

Case Investigation Status Code, from NBS MM
Detection Method, from NBS MM
Age of patient at cough onset
Age units at cough onset
Was the case laboratory confirmed?
Was a specimen sent to CDC for testing?
What type of testing was done at CDC for this subject?
If other, specify testing done at CDC
Date specimen sent to CDC
VPD Lab Message Patient Identifier
VPD Lab Message Observation Identifier
VPD Lab Message Observation Value
If other, specify lab test
Specimen ID Placer Assigned Identifier
Specimen ID Filler Assigned Identifier
Performing Laboratory Type
If other, specify performing laboratory type
Numeric Result Value
The unit of measure for numeric result value.
Was subject vaccinated as recommended by ACIP?
Reason subject not vaccinated as recommended by ACIP
If other, specify reason not vaccinated per ACIP
If other, specify type of vaccine administered
NDC from the vaccine’s bar code. With the NDC code, vaccine brand name and
manufacturer can be obtained.
If other, specify vaccine manufacturer
Vaccine expiration date
Vaccination Record ID, from NBS MM
Reason subject was not vaccinated, regardless of the immunization schedule used
If other, specify the other transmission setting
If other, specify transmission setting of further spread
Suspexcted source of infection relationship to case
Estimated cough onset date of suspected source of infection

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_ChestXrayResult_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_AntibioticReceived_Pertussis

PHVS_AntibioticReceived_Pertussis

PHVS_YesNoUnknown_CDC
PHVS_LabTestProcedure_Pertussis
PHVS_LabTestInterpretation_Pertussis
PHVS_YesNoUnknown_CDC
PHVS_VaccinesAdministeredCVX_CDC_NIP
PHVS_ManufacturersOfVaccinesMVX_CDC_NIP

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_TransmissionSetting_NND

PHVS_YesNoUnknown_CDC

Age_Type
PHVS_TransmissionSetting_NND

PHVS_Relationship_Flu

Label/Short Name
Primary plague type
Animal Contact
Flea bite

Description
Classification of primary clinical manifestation of infection
Contact with sick or dead animals
Flea bite

Value Set Code. Search in PHIN VAD
Bubonic/Septicemic/Pneumonic/Ot
Animal bite/Animal scratch/Coughe
Known flea bite/Likely flea bite/No

Code. Search in PHIN VADS using the following link (https://phinvads.cdc.gov/vads/SearchHome.action)
Septicemic/Pneumonic/Other
te/Animal scratch/Coughed on by animal/handled animal
a bite/Likely flea bite/No flea bite/Unknown

Label/Short Name
Paralysis onset date
Clinical course
CSF date
WBCs
RBCs
%Lymph
%polys
Protein
Glucose
60-day follow up date
Paralysis site
Specific sites
60-day residual
TOPV immunization history
Date of TOPV
Lot number
IPV-containing vaccine
Date 1 IPV
Date 2 IPV
Date 3 IPV
TOPV vaccine
Date 1 TOPV
Date 2 TOPV
Date 3 TOPV
BOPV vaccine
Date 1 BOPV
Date 2 BOPV
Date 3 BOPV
MOPV vaccine
Date 1 MOPV
Date 2 MOPV
Date 3 MOPV
First injection date
Substance
Describe
First injection site
Second injection date
Substance
Describe
Second injection site
Third injection date
Substance
Describe

Third injection site
Fourth injection date
Substance
Describe
Fourth injection site
Travel to endemic/epidemic area(s)
Exposure location(s) 1
Departure date 1
Return date 1
Exposure to person(s) from or
returning to endemic areas
Exposure location(s) 2
Departure date 2
Return date 2
Contact with known case
Contact name
Exposure to case location
Contact date
OVP recipient contact
OVP recipient contact
OVP recipient relation
OVP recipient age
OPV recipient agetype
Date received OVP
OVP dose number
OVP lot number
State or local laboratory name
Serum 1
Serum 1 test type
Serum 1 result
Serum 1 date
Serum 2
Serum 2 test type
Serum 2 result
Serum 2 date
Specimen 1 results
Specimen 1 laboratory
Specimen 1 type
Specimen 1 date
Specimen 2 results
Specimen 2 laboratory
Specimen 2 type
Specimen 2 date
CDC serum 1

CDC serum 1 test type
CDC serum 1 result
CDC serum 1 date
CDC serum 2
CDC serum 2 test type
CDC serum 2 result
CDC serum 2 date
CDC specimen 1 type
CDC specimen 1 results
CDC specimen 1 strain results
CDC specimen 1 date received
CDC specimen 1 obtained
CDC specimen 2 type
CDC specimen 2 results
CDC specimen 2 strain results
CDC specimen 2 date received
CDC specimen 2 obtained
EMG
EMG results
EMG date
Nerve conduction
Nerve results
Nerve conduction date
Immune deficiency
Immune deficiency diagnosis
Immune studies
HIV status

Description
Date of onset of paralysis
Clinical course
Date of CSF results
White blood cell test results for cerebral spinal fluid
Red blood cell test results for cerebral spinal fluid
%lymphs test results for CSF
%polys test results for CSF
Protein test results for CSF
Glucose test results for CSF
Date of 60-day follow up
Sites of paralysis
Specific sites of paralysis
60-day paralysis residual
TOPV within 30 days prior to onset of symptoms?
TOPV immunization date
TOPV vaccine lot number
Total doses ever received of IPV-containing vaccine
First IPV vaccine date
Second IPV vaccine date
Third IPV vaccine date
Total doses ever received of TOPV vaccine
First TOPV vaccine date
Second TOPV vaccine date
Third TOPV vaccine date
Total doses ever received of BOPV vaccine
First BOPV vaccine date
Second BOPV vaccine date
Third BOPV vaccine date
Total doses ever received of MOPV vaccine
First MOPV vaccine date
Second MOPV vaccine date
Third MOPV vaccine date
Date of first injection received within 30 days prior to onset of illness
Substance (vaccine, antibiotic, other) of first injection
Description of first injection substance
Site of first injection
Date of second injection received within 30 days prior to onset of illness
Substance (vaccine, antibiotic, other) of second injection
Description of second injection substance
Site of second injection
Date of third injection received within 30 days prior to onset of illness
Substance (vaccine, antibiotic, other) of third injection
Description of third injection substance

Site of third injection
Date of fourth injection received within 30 days prior to onset of illness
Substance (vaccine, antibiotic, other) of fourth injection
Description of fourth injection substance
Site of fourth injection
Did case/household member travel to endemic/epidemic area(s)?
Locations of exposure of case/household member
Date of travel departure
Date of travel return
Was case/household members exposed to persons from or returning to endemic
areas?
Locations of exposure to case/household member who traveled/is from endemic area
Date of travel departure of person to whom exposed
Date of travel return of person to whom exposed
Did case/household member have contact with known case?
Name of case contact (last, first)
Location of exposure to case?
Date of contact with known case
Did case have contact with OPV vaccine recipient
If yes, date of contact with household OVP vaccine
Relationship of household OVP vaccine recipient to case
Age of the OVP vaccine recipient
Agetype of the OVP vaccine recipient
Date contact received OVP vaccine
Number of doses of OVP vaccine received by contact
Lot number of OVP vaccine received by contact
Name of state or local laboratory which received serum specimens
Indicate whether P1, P2, or P3
Test type (neut/CSF)
Test result for serum 1
Date drawn/obtained for serum1
Indicate whether P1, P2, or P3
Test type (neut/CSF)
Test result for serum 2
Date drawn/obtained for serum 2
Results of specimen 1 sent for viral isolation
Name of laboratory which received specimens for viral isolation
Type specimen 1 submitted for viral isolation
Date drawn/obtained for specimen 1
Results of specimen 2 sent for viral isolation
Name of laboratory which received specimens for viral isolation
Type specimen 2 submitted for viral isolation
Date drawn/obtained for specimen 2
Indicate whether P1, P2, or P3 (serum sent to CDC lab)

Test type (neut/CSF for serum sent to CDC lab)
Test result for serum 1 (sent to CDC lab)
Date drawn/obtained for serum 1 (sent to CDC)
Indicate whether P1, P2, or P3
Test type (neut/CSF for serum sent to CDC lab))
Test result for serum 2 (sent to CDC lab)
Date drawn/obtained for serum 2 (sent to CDC lab)
Type specimen 1 submitted for viral isolation (to CDC lab)
Results of specimen 1 sent for viral isolation (to CDC lab)
Strain characterization results for specimen 1
Date specimen 1 received by CDC lab
Date specimen 1 obtained for CDC testing
Type specimen 2 submitted for viral isolation (to CDC lab)
Results of specimen 2 sent for viral isolation (to CDC lab)
Strain characterization results for specimen 2
Date specimen 2 received by CDC lab
Date specimen 2 obtained for CDC testing
Was an EMG performed?
What were the results of the EMG?
Indicate date of EMG.
Was a nerve conduction performed?
What were the results of the nerve conduction?
Indicate date of the nerve conduction.
Was an immune deficiency diagnosed prior to OPV exposure?
What was thespecific diagnosi?s
Indicate any immune studies performed
Wehat is the HIV status of the patient?

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

Label/Short Name
Clinical course
CSF date
WBCs
RBCs
%Lymph
%polys
Protein
Glucose
60-day follow up date
TOPV immunization history
Date of TOPV
Lot number
IPV-containing vaccine
Date 1 IPV
Date 2 IPV
Date 3 IPV
TOPV vaccine
Date 1 TOPV
Date 2 TOPV
Date 3 TOPV
BOPV vaccine
Date 1 BOPV
Date 2 BOPV
Date 3 BOPV
MOPV vaccine
Date 1 MOPV
Date 2 MOPV
Date 3 MOPV
First injection date
Substance
Describe
First injection site
Second injection date
Substance
Describe
Second injection site
Third injection date
Substance
Describe
Third injection site
Fourth injection date
Substance
Describe

Fourth injection site
Travel to endemic/epidemic area(s)
Exposure location(s) 1
Departure date 1
Return date 1
Exposure to person(s) from or
returning to endemic areas
Exposure location(s) 2
Departure date 2
Return date 2
Contact with known case
Contact name
Exposure to case location
Contact date
OVP recipient contact
OVP recipient contact
OVP recipient relation
OVP recipient age
OPV recipient agetype
Date received OVP
OVP dose number
OVP lot number
State or local laboratory name
Serum 1
Serum 1 test type
Serum 1 result
Serum 1 date
Serum 2
Serum 2 test type
Serum 2 result
Serum 2 date
Viral Isolation Specimen 1 results
Specimen 1 laboratory
Specimen 1 type
Specimen 1 date
Specimen 2 results
Specimen 2 laboratory
Specimen 2 type
Specimen 2 date
CDC serum 1
CDC serum 1 test type
CDC serum 1 result
CDC serum 1 date
CDC serum 2

CDC serum 2 test type
CDC serum 2 result
CDC serum 2 date
CDC specimen 1 type
CDC specimen 1 results
CDC specimen 1 strain results
CDC specimen 1 date received
CDC specimen 1 obtained
CDC specimen 2 type
CDC specimen 2 results
CDC specimen 2 strain results
CDC specimen 2 date received
CDC specimen 2 obtained
EMG
EMG results
EMG date
Nerve conduction
Nerve results
Nerve conduction date
Immune deficiency
Immune deficiency diagnosis
Immune studies
HIV status

Description
Clinical course
Date of CSF results
White blood cell test results for cerebral spinal fluid
Red blood cell test results for cerebral spinal fluid
%lymphs test results for CSF
%polys test results for CSF
Protein test results for CSF
Glucose test results for CSF
Date of 60-day follow up
TOPV within 30 days prior to onset of symptoms?
TOPV immunization date
TOPV vaccine lot number
Total doses ever received of IPV-containing vaccine
First IPV vaccine date
Second IPV vaccine date
Third IPV vaccine date
Total doses ever received of TOPV vaccine
First TOPV vaccine date
Second TOPV vaccine date
Third TOPV vaccine date
Total doses ever received of BOPV vaccine
First BOPV vaccine date
Second BOPV vaccine date
Third BOPV vaccine date
Total doses ever received of MOPV vaccine
First MOPV vaccine date
Second MOPV vaccine date
Third MOPV vaccine date
Date of first injection received within 30 days prior to onset of illness
Substance (vaccine, antibiotic, other) of first injection
Description of first injection substance
Site of first injection
Date of second injection received within 30 days prior to onset of illness
Substance (vaccine, antibiotic, other) of second injection
Description of second injection substance
Site of second injection
Date of third injection received within 30 days prior to onset of illness
Substance (vaccine, antibiotic, other) of third injection
Description of third injection substance
Site of third injection
Date of fourth injection received within 30 days prior to onset of illness
Substance (vaccine, antibiotic, other) of fourth injection
Description of fourth injection substance

Site of fourth injection
Did case/household member travel to endemic/epidemic area(s)?
Locations of exposure of case/household member
Date of travel departure
Date of travel return
Was case/household members exposed to persons from or returning to endemic
areas?
Locations of exposure to case/household member who traveled/is from endemic area
Date of travel departure of person to whom exposed
Date of travel return of person to whom exposed
Did case/household member have contact with known case?
Name of case contact (last, first)
Location of exposure to case?
Date of contact with known case
Did case have contact with OPV vaccine recipient
If yes, date of contact with household OVP vaccine
Relationship of household OVP vaccine recipient to case
Age of the OVP vaccine recipient
Agetype of the OVP vaccine recipient
Date contact received OVP vaccine
Number of doses of OVP vaccine received by contact
Lot number of OVP vaccine received by contact
Name of state or local laboratory which received serum specimens
Indicate whether P1, P2, or P3
Test type (neut/CSF)
Test result for serum 1
Date drawn/obtained for serum1
Indicate whether P1, P2, or P3
Test type (neut/CSF)
Test result for serum 2
Date drawn/obtained for serum 2
Results of specimen 1 sent for viral isolation
Name of laboratory which received specimens for viral isolation
Type specimen 1 submitted for viral isolation
Date drawn/obtained for specimen 1
Results of specimen 2 sent for viral isolation
Name of laboratory which received specimens for viral isolation
Type specimen 2 submitted for viral isolation
Date drawn/obtained for specimen 2
Indicate whether P1, P2, or P3 (serum sent to CDC lab)
Test type (neut/CSF for serum sent to CDC lab)
Test result for serum 1 (sent to CDC lab)
Date drawn/obtained for serum 1 (sent to CDC)
Indicate whether P1, P2, or P3

Test type (neut/CSF for serum sent to CDC lab))
Test result for serum 2 (sent to CDC lab)
Date drawn/obtained for serum 2 (sent to CDC lab)
Type specimen 1 submitted for viral isolation (to CDC lab)
Results of specimen 1 sent for viral isolation (to CDC lab)
Strain characterization results for specimen 1
Date specimen 1 received by CDC lab
Date specimen 1 obtained for CDC testing
Type specimen 2 submitted for viral isolation (to CDC lab)
Results of specimen 2 sent for viral isolation (to CDC lab)
Strain characterization results for specimen 2
Date specimen 2 received by CDC lab
Date specimen 2 obtained for CDC testing
Was an EMG performed?
What were the results of the EMG?
Indicate date of EMG.
Was a nerve conduction performed?
What were the results of the nerve conduction?
Indicate date of the nerve conduction.
Was an immune deficiency diagnosed prior to OPV exposure?
What was thespecific diagnosi?s
Indicate any immune studies performed
Wehat is the HIV status of the patient?

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

Label/Short Name
Clinical description
Specific therapy
Outcome
Death date
Acute-phase serum
Acute-phase serum collected
Acute-phase serum IgM test result
Acute-phase serum IgG test result
Acute-phase serum lab
Convalescent-phase serum
Convalescent-phase serum collected
Convalescent-phase serum IgM test
result
Convalescent-phase serum IgG test
result
Convalescent-phase serum lab
PCR
PCR collected
PCR test result
PCR specimen lab
Sputum culture collected
Sputum culture test result
Sputum culture lab
Chest x-ray
Chest x-ray date
Chest x-ray results
Onset Date Occupation
Specific duties
Contact types prior to onset
Psittacine contact
Pigeons
Domestic fowl
Other birds
Healthy birds
Private home - owner
Private home - adress
Private home - species

Private home - setting
Private home - date
Private aviary - owner
Private aviary - adress
Private aviary - species
Private aviary -setting
Private aviary - date
Coomercial aviary - owner
Coomercial aviary - address
Coomercial aviary - species
Coomercial aviary - setting
Coomercial aviary - date
Pet shop - owner
Pet shop - address
Pet shop - species
Pet shop - setting
Pet shop - date
Bird loft - owner
Bird loft - address
Bird loft - species
Bird loft - setting
Bird loft - date
Poultry establishment - owner
Poultry establishment - address
Poultry establishment - species
Poultry establishment - setting
Poultry establishment - date
Other - owner
Other - address
Other - species
Other - setting
Other - date
Unknown - owner
Unknown - address
Unknown - species
Unknown - setting
Unknown - date
Other epi link
Implicated birds

Additional revelant information

Description
Check all signs and symptoms listed below (note maximum temperature). Thi is a
multi-select field.
Specify products, dosage, and duration.
What was the outcome of this illness?
If patient died, date of death.
What was the acute-phase serum test method?
What was the acute-phase serum collection date?
What was the acute-phase serum IgM result?
What was the acute-phase serum IgG result?
What was the laboratory name?
What was the convalescent-phase serum test method?
What was the convalescent-phase serum collection date?
What was the convalescent-phase serum IgM result?
What was the convalescent-phase serum IgG result?
What was the laboratory name?
What was the PCR test specimen type?
What was the PCR specimen collection date?
What was the PCR test result?
What was the laboratory name?
What was the sputum specimen collection date?
What was the sputum specimen test result?
What was the laboratory name?
Was a chest x-ray done?
When was the chest x-ray done?
What was the chest x-ray result?
What was the patient's occupation at date of onset?
What are/were the patient's specific duties?
Indicate which of the following contacts the patient had during the 5 weeks prior to
onset.
If exposure to birds, did the patient have contact with psittacines (species, approx
number and were birds healthy)?
If exposure to birds, did the patient have contact with pigeons (species, approx number
and were birds healthy)?
If exposure to birds, did the patient have contact with domestic fowl (species, approx
number and were birds healthy)?
If exposure to birds, did the patient have contact with any other birds (species, approx
number and were birds healthy)?
If birds were not healthy, please elaborate.
Indicate the owner of the private home
Indicate the address of the private home
Indicate the species to which exposed

Indicate the exposure setting (indoor, outdoor)
Indicate the date of exposure
Indicate the owner of the aviary
Indicate the address of the aviary
Indicate the species to which exposed
Indicate the exposure setting (indoor, outdoor)
Indicate the date of exposure
Indicate the owner of the aviary
Indicate the address of the aviary
Indicate the species to which exposed
Indicate the exposure setting (indoor, outdoor)
Indicate the date of exposure
Indicate the owner of the pet shop
Indicate the address of the pet shop
Indicate the species to which exposed
Indicate the exposure setting (indoor, outdoor)
Indicate the date of exposure
Indicate the owner of the bird loft
Indicate the address of the bird loft
Indicate the species to which exposed
Indicate the exposure setting (indoor, outdoor)
Indicate the date of exposure
Indicate the owner of the establishment
Indicate the address of the establishment
Indicate the species to which exposed
Indicate the exposure setting (indoor, outdoor)
Indicate the date of exposure
Indicate the owner of the 'other'
Indicate the address of the 'other'
Indicate the species to which exposed
Indicate the exposure setting (indoor, outdoor)
Indicate the date of exposure
Indicate the owner unknown
Indicate the address unknown
Indicate if species to which exposed unknown
Indicate if exposure setting (indoor, outdoor) is unknown
Indicate if the date of exposure is unknown
Indicate if any other epi linkage (specify)
If pet birds, domestic pigeons, or fowl are implicated as the source of the human
psittacosis, list address of every known place where the birds were harbored and
approx dates.
Indicate any additional revelant information

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

Label/Short Name
Wool or Felt Plant
Tannery or Rendering
Dairy
Veterinarian
Medical Researcher
Animal Researcher
Slaughterhouse
Laboratory
Rancher
Lives in Household
Military
Other Occupation
Cattle Contact
Sheep Contact
Goat Contact
Pigeon Contact
Cat Contact
Rabbit Contact
Other Animal Contact
Exposure to Birthing Animals
Exposure to Unpasteurized Milk
Milk Animal
Other Family Ill
Fever
Myalgia
Retro Orbital Pain
Malaise
Rash
Cough
Headache
Splenomegaly
Hepatomegaly
Pneumonia
Hepatitis
Endocarditis
Other Signs or Symptoms
Immunocompromised
Pregnant
Valvular Disease
Other Pre-existing Medical Condition

Laboratory Name
Laboratory State
Acute Phase I Serology Collection
Date
Acute Phase I IFA IgG Result
Acute Phase I IFA IgG Titer
Acute Phase I IFA IgM Result
Acute Phase I IFA IgM Titer
Acute Phase I Compliment Fixation
Result
Acute Phase I Compliment Fixation
Titer
Acute Phase I, Other Test Name
Acute Phase I, Other Test Result
Acute Phase I, Other Test Numeric
Result
Acute Phase II Serology Collection
Date
Acute Phase II IFA IgG Result
Acute Phase II IFA IgG Titer
Acute Phase II IFA IgM Result
Acute Phase II IFA IgM Titer
Acute Phase II Compliment Fixation
Result
Acute Phase II Compliment Fixation
Titer
Acute Phase II, Other Test Name
Acute Phase II, Other Test Result
Acute Phase II, Other Test Numeric
Result
Convalescent Phase I Serology
Collection Date
Convalescent Phase I IFA IgG Result
Convalescent Phase I IFA IgG Titer
Convalescent Phase I IFA IgM Result
Convalescent Phase I IFA IgM Titer
Convalescent Phase I Compliment
Fixation Result
Convalescent Phase I Compliment
Fixation Titer
Convalescent Phase I, Other Test
Name
Convalescent Phase I, Other Test
Result

Convalescent Phase I, Other Test
Numeric Result
Convalescent Phase II Serology
Collection Date
Convalescent Phase II IFA IgG Result
Convalescent Phase II IFA IgG Titer
Convalescent Phase II IFA IgM Result
Convalescent Phase II IFA IgM Titer
Convalescent Phase II Compliment
Fixation Result
Convalescent Phase II Compliment
Fixation Titer
Convalescent Phase II, Other Test
Name
Convalescent Phase II, Other Test
Result
Convalescent Phase II, Other Test
Numeric Result
Fourfold
PCR
Immunostain
Culture

Description
Did the case work in a wool or felt plant
Did the case work in a tannery or rendering plant
Did the case work in a dairy
Did the case work as a veterinarian
Did the case work as a medical researcher
Did the case work as an animal researcher
Did the case work in a slaughterhouse
Did the case work in a laboratory
Did the case work as a rancher
Did the case live in a household with someone who may have one of the above
occupational exposures
Did the case work in the military
Indicate the case's occupation if none of the above
Did the case have contact with cattle within two months of illness onset
Did the case have contact with sheep within two months of illness onset
Did the case have contact with goats within two months of illness onset
Did the case have contact with pigeons within two months of illness onset
Did the case have contact with cats within two months of illness onset
Did the case have contact with rabbits within two months of illness onset
Indicate any other animals the case had contact within within two months of illness
onset
Was the case exposed to birthing animals within two months of illness onset
Was the case exposed to unpasteurized milk within two months of illness onset
If the case was exposed to unpasteurized milk, what animal was the milk from
Was another family member ill with a similar illness within the last year
Did the case report a fever of at least 100.5 during this illness
Did the case report myalgia during this illness
Did the case report retro orbital pain during this illness
Did the case report malaise during this illness
Did the case report a rash during this illness
Did the case report a coughduring this illness
Did the case report a headache during this illness
Did the case report splenomegaly during this illness
Did the case report hepatomegaly during this illness
Did the case report pneumonia during this illness
Did the case report hepatitis during this illness
Did the case report endocarditis during this illness
If there were other signs or symptoms reported, the indicate them here
Did the case report a pre-existing immunocompromised system
Was the case pregnant during this illness
Did the case have a pre-existing valvular heart disease or graft
If the case had nother pre-existing medical conditions, then list them here

Indicate the name of the laboratory which supplied results supporting the current CSTE
case definitions.
Indicate the state where the laboratory is located
If acute phase I serology was performed, then list the date of collection
If performed, was the acute phase I IFA IgG positive
If performed, what was the reciprocal titer of the acute phase I IFA IgG
If performed, was the acute phase I IFA IgM positive
If performed, what was the reciprocal titer of the acute phase I IFA IgM
If performed, was the acute phase I compliment fixation positive
If performed, what was the reciprocal titer of the acute phase I compliment fixation
If performed, what was the name of another phase I acute serologic test
If performed, was the other phase I acute serologic test positive
If performed, what was the numeric result of the other phase I acute serologic test
If acute phase II serology was performed, then list the date of collection
If performed, was the acute phase II IFA IgG positive
If performed, what was the reciprocal titer of the acute phase II IFA IgG
If performed, was the acute phase II IFA IgM positive
If performed, what was the reciprocal titer of the acute phase II IFA IgM
If performed, was the acute phase II compliment fixation positive
If performed, what was the reciprocal titer of the acute phase II compliment fixation
If performed, what was the name of another phase II acute serologic test
If performed, was the other phase II acute serologic test positive
If performed, what was the numeric result of the other phase II acute serologic test
If convalescent phase I serology was performed, then list the date of collection
If performed, was the convalescent phase I IFA IgG positive
If performed, what was the reciprocal titer of the convalescent phase I IFA IgG
If performed, was the convalescent phase I IFA IgM positive
If performed, what was the reciprocal titer of the convalescent phase I IFA IgM
If performed, was the convalescent phase I compliment fixation positive
If performed, what was the reciprocal titer of the convalescent phase I compliment
fixation
If performed, what was the name of another phase I convalescent serologic test
If performed, was the other phase I convalescent serologic test positive

If performed, what was the numeric result of the other phase I convalescent serologic
test
If convalescent phase II serology was performed, then list the date of collection
If performed, was the convalescent phase II IFA IgG positive
If performed, what was the reciprocal titer of the convalescent phase II IFA IgG
If performed, was the convalescent phase II IFA IgM positive
If performed, what was the reciprocal titer of the convalescent phase II IFA IgM
If performed, was the convalescent phase II compliment fixation positive
If performed, what was the reciprocal titer of the convalescent phase II compliment
fixation
If performed, what was the name of another phase II convalescent serologic test
If performed, was the other phase II convalescent serologic test positive
If performed, what was the numeric result of the other phase II convalescent serologic
test
If paired sera were collected, was there a fourfold change in titer between acute and
convalescent of the same phase
If performed, was the polymerase chain reaction assay positive
If performed, were antibodies detected using immunohistochemistry during
microscopy
If performed, was the etiologic agent isolated from culture

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_State_FIPS_5-2

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

Label/Short Name
Did the subject have a rash?
Rash onset date
Duration of rash
Rash Onset occur within 14-23 days
of entering USA
Did the Subject have a fever?
Highest Measured Temperature
Temperature Units
Date of Fever Onset
Arthralgia/arthritis (symptom)
Lymphadenopathy (symptom)
Conjunctivitis (symptom)
Encephalitis
(complication)
Thrombocytopenia
(complication)
Arthralgia/arthritis (complication)
Other Complication
Specify Other Complication
Cause of Death
Was laboratory testing done for
rubella?
Test Type
Test Result
Sample Analyzed Date
Test Method
Date Collected
Specimen Source
Were the specimens sent to CDC for
genotyping (molecular typing)?
Specimen type sent to CDC for
genotyping
Date sent for genotyping
Was Rubella genotype sequenced?
Type of Genotype Sequence
Transmission Setting
Were age and setting verified?

Source of Infection
Is this case Epi-linked to another
confirmed or probable case?

Traceable to international import?
Expected Delivery Date
Expected Place of Delivery
Number of weeks gestation at time
of disease
Trimester of gestation at time of
disease
Documentation of previous disease
immunity testing
Result of previous immunity testing
Year of previous immunity testing
Age of Subject at time of immunity
testing (in years)
Did the Subject ever have this
disease prior to this pregnancy?
Was previous disease serologically
confirmed?
Year of previous disease
Age of the Subject at time of
previous disease (in years)
Current Pregnancy Outcome
At the time of cessation of
pregnancy, what was the age of the
fetus (in weeks)?
Was an autopsy performed?
Final Anatomical Diagnosis of Death
from Autopsy Report
Did the Subject ever receive diseasecontaining vaccine?
If no, reason subject did not receive a
disease-containing vaccine
Number of doses received ON or
AFTER first birthday
Vaccine Administered
Vaccine Manufacturer
Vaccine Lot Number
Vaccine Administered Date
US Acquired

Description
Did the subject being reported in this investigation have a rash?
What was the rash onset date?
How many days did the rash last?
Did rash onset occur 14-23 days after entering USA, following any travel or living
outside the USA?
Did the subject have a fever? i.e., a measured temperature >2 degrees above normal
What was the person's highest measured temperature during this illness?
The units of measure of the highest measured temperature. This would be either
Fahrenheit or Celsius.
Date of fever onset
Did the Subject have arthralgia/arthritis (symptom)?
Did the Subject have lymphadenopathy (symptom)?
Did the Subject have conjunctivitis (symptom)?
Did the person develop encephalitis as a complication of this illness?
Did the person develop thrombocytopenia as a complication of this illness?
Did Subject have arthralgia/arthritis (complication)?
Did the person develop an other condition(s) as a complication of this illness?
Please specify the other complication(s) the person developed, during or as a result of
this illness.
Cause of subject's death
Was laboratory testing done for rubella?
Epidemiologic interpretation of the type of test(s) performed for this case
Epidemiologic interpretation of the results of the tests performed for this case
The date the specimen/isolate was tested
The technique or method used to perform the test and obtain the test results
Date of specimen collection
The medium from which the specimen originated
Were clinical specimens sent to CDC laboratories for genotyping (molecular typing)?
Specimen type sent to CDC for genotyping
The date the specimens were sent to the CDC laboratories for genotyping
Identifies whether the Rubella virus was genotype sequenced.
Identifies the genotype sequence of the Rubella virus
What was the transmission setting where the Rubella was acquired?
Does the age of the case match or make sense for the transmission setting listed (i.e.) a
person aged 80 probably would not have a transmission setting of child day care
center?
What was the source of the Rubella infection?
Specify if this case is Epidemiologically-linked to another confirmed or probable case of
Rubella?

Identifies whether the Rubella case was traceable (linked) to an international import.
What is the expected delivery date of this pregnancy?
Expected place of delivery
Number of weeks gestation at time of rubella disease
Trimester of gestation at time of rubella disease
Is there documentation of previous rubella immunity testing?
Result of previous immunity testing
Year of previous immunity testing
Age of Subject at time of immunity testing
Did the Subject ever have rubella disease prior to this pregnancy?
Was previous rubella disease serologically confirmed?
If previous rubella was serologically confirmed, what was the year of previous disease?
If previous rubella was serologically confirmed, what was the age of the Subject at time
of previous disease?
What was the outcome of the current pregnancy?
If applicable, at the time of cessation of pregnancy, what was the age of the fetus (in
weeks)?
Was an autopsy performed on the subject's body?
The final anatomical cause of subject's death
Did the Subject ever receive rubella-containing vaccine?
If the subject did not receive a rubella-containing vaccine, what was the reason?

Number of rubella-containing vaccine doses Subject received ON or AFTER first
birthday
The type of vaccine administered, (e.g., Varivax, MMRV). First question of a repeating
group of vaccine questions.
Manufacturer of the vaccine. Second question of a repeating group of vaccine
questions.
The vaccine lot number of the vaccine administered. Third question of a repeating
group of vaccine questions.
The date that the vaccine was administered. Fourth question of a repeating group of
vaccine questions.
Sub-classification of disease or condition acquired in the US

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_TemperatureUnit_UCUM

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_LabTestProcedure_Rubella
PHVS_LabTestInterpretation_VPD
PHVS_LabTestMethod_CDC
PHVS_SpecimenSource_VPD
PHVS_YesNoUnknown_CDC
PHVS_SpecimenSource_VPD

PHVS_YesNoUnknown_CDC
PHVS_Genotype_Rubella
PHVS_TransmissionSetting_NND
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_PregnancyTrimester_CDC
PHVS_YesNoUnknown_CDC
PHVS_LabTestInterpretation_VPD

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_BirthOutcome_Rubella

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_VaccineNotGivenReasons_CDC

PHVS_VaccinesAdministeredCVX_CDC_NIP
PHVS_ManufacturersOfVaccinesMVX_CDC_NIP

PHVS_CaseClassificationExposureSource_NND

Label/Short Name
AgClinic
AgClinicTestType
AgeMnth
AgeYr
AgSphl
AgSphlTestType
BioId
BloodyDiarr
Diarrhea
DtAdmit2
DtDisch2
DtEntered
DtRcvd
DtRptComp
DtSpec
DtUSDepart
DtUSReturn
EforsNum
Fever
HospTrans
Immigrate
Interview
LabName
LocalID
OtherCdcTest
OtherClinicTest
OtherClinicTestType
OtherSphlTest
OtherSphlTestType
OutbrkType
PatID
PcrCdc
PcrClinic
PcrClinicTestType
PcrSphl

PersonID
ResultID
RptComp
SalGroup
SentCDC
SeroSite
SLabsID
SpecSite
StLabRcvd

TravelDest
TravelInt
Dom_travel
Out_freq
Chx_handle
Chicken
Chx_uncook
chx_ground
Chx_whole
chx_processed
Chx_outside
Chx_home
Chx_fresh
Chx_frozen
Turkey_handle
Turkey
Turkey_uncook
Turkey_ground
Turkey_whole
Turkey_processed
Turkey_outside

Turkey_home
Other_poultry
Beef_handle
Beef
Beef_uncook
Beef_ground
Beef_whole
Beef_processed
Beef_outside
Beef_home
Beef_fresh
Beef_frozen
Pork_handle
Pork
Pork_uncook
Pork_whole
Pork_processed
Lamb
Seafood
seafood_uncook
Fish
Fish_uncook
Fish_whole
Eggs
Eggs_outside
Eggs_home

Eggs_uncook
Dairy
Queso_fresco
Dairy_uncook
Cantaloupe
Strawberries
Other_berries
Watermelon
Apples
Honeydew
Pineapple
Raw_cider
Other_fruit
Nuts_uncook
Lettuce
Cabbage
Spinach
Broccoli
Tomatoes
Onions
Carrots
Sprouts
Herbs
Other_veggies
Infant_formula

Infant_bmilk
Infant_omilk
Well_water
Other_untreated
Swim_unchlor
Sick_contacts
Diaper_contact
Shared_facility
Daycare
Sick_pet
Reptile_amphib
Outdoors
Manure_compost
Farm_ranch
Live_poultry
Cattle_others
Other_animals
Site ID
Disease
State Lab ID
Collection Date
Last Updated
Confirmed
Specimen Source
Test Result
Local Case ID
City
State
Zip code
County
DOB
Age

Age Type
Sex
Race
Ethnicity
Comments

Description
What was the result of specimen testing using an antigen-based test (e.g. EIA or lateral
flow) at a clinical laboratory?
Name of antigen-based test used at clinical laboratory
Age of case-patient in months if patient is <1yr
Age of case-patient in years
What was the result of specimen testing using an antigen-based test (e.g. EIA or lateral
flow) at a state public health laboratory?
Name of antigen-based test used at state public health laboratory
Was the pathogen identified by culture?
Did the case-patient have bloody diarrhea (self reported) during this illness?
Did the case-patient have diarrhea (self-reported) during this illness?
Date of hospital admission for second hospitalization for this illness
Date of hospital discharge for second hospitalization for this illness
Date case was entered into site's database
Date case-pateint's specimen was received in laboratory for initial testing
Date case report form was completed
Case-patient's specimen collection date
If case-patient patient traveled internationally, date of departure from the U.S.
If case-patient traveled internationally, date of return to the U.S.
CDC FDOSS outbreak ID number
Did the case-patient have fever (self-reported) during this illness?
If case-patient was hospitalized, was s/he transferred to another hospital?
Did case-patient immigrate to the U.S.? (within 7 days of illness onset)
Was the case-patient interviewed by public health (i.e. state or local health
department) ?
Name of submitting laboratory
Ccase-patient's medical record number
What was the result of specimen testing using another test at CDC?
What was the result of specimen testing using another test at a clinical laboratory?
Name of other test used at a clinical laboratory
What was the result of specimen testing using another test at a state public health
laboratory?
Name of other test used at a state public health laboratory
Type of outbreak that the case-patient was part of
Case-patient identification number
What was the result of specimen testing for diagnosis using PCR at CDC? (Do not enter
PCR results if PCR was performed for speciation or subtyping).
What was the result of specimen testing using PCR at a clinical laboratory? (where goal
of testing is primary detection not subtyping or speciation)
Name of PCR assay used
What was the result of specimen testing for diagnosis using PCR at the state public
health laboratory? (Do not enter PCR results if PCR was performed for speciation or
subtyping).

Unique identification number for person or patient
Unique identifier for laboratory result
Is all of the information for this case complete?
Salmonella serogroup
Was specimen or isolate forwarded to CDC for testing or confirmation?
Serotype/species of pathogen
State lab identification number
Case patient's specimen collection source
Was the isolate sent to a state public health laboratory? (Answer 'Yes' if it was sent to
any state lab, even if it was sent to a lab outside of the case's state of residence)
If case-patient traveled internationally, to where did they travel?
Did the case patient travel internationally? (within 7 days of onset)
In the 7 days before illness, would you/your child have traveled within the US but
outside of the area where you live or work?
How many times would you/your child have eaten out (deli, fast food, or other
restaurant)?
Would you/your child, or anyone in your household, have handled raw chicken in the
home?
How many times would you/your child have eaten chicken or any foods containing
chicken?
In the 7 days before illness, would you/your child have eaten any chicken that was raw
or undercooked?
In the 7 days before illness, would you/your child have eaten any ground chicken?
In the 7 days before illness, would you/your child have eaten any whole or cut chicken
parts (e.g., rotisserie, chicken breasts, wings, etc.)?
In the 7 days before illness, would you/your child have eaten any processed chicken
(e.g., deli meat, chicken nuggets, pre-made dinners, etc.)?
In the 7 days before illness, would you/your child have eaten any chicken made outside
of home (deli, fast food, take-out, or restaurant)?**
In the 7 days before illness, would you/your child have eaten any chicken made at
home?
Was the chicken bought fresh (refrigerated)? (Answer if Yes to Q56)
Was the chicken bought frozen? (Answer if Yes to Q56)
Would you/your child, or anyone in your household, have handled raw turkey in the
home?
In the 7 days before illness, would you/your child have eaten any turkey or any foods
containing turkey?
In the 7 days before illness, would you/your child have eaten any turkey that was
undercooked or raw?
In the 7 days before illness, would you/your child have eaten any ground turkey?
In the 7 days before illness, would you/your child have eaten any whole or cut turkey
parts?
In the 7 days before illness, would you/your child have eaten any processed turkey
(e.g., deli meat, bacon, sausage, pre-made dinners, etc.)?**
In the 7 days before illness, would you/your child have eaten any turkey made outside
of home (deli, fast food, take-out, or restaurant)?

In the 7 days before illness, would you/your child have eaten any turkey made at
home?
In the 7 days before illness, would you/your child have eaten any poultry other than
chicken or turkey (e.g., duck, cornish hens, quail, etc.)?
Would you/your child, or anyone in household, have handled raw beef in the home?
In the 7 days before illness, would you/your child have eaten beef or any foods
containing beef?
In the 7 days before illness, would you/your child have eaten any beef that was
undercooked or raw?
In the 7 days before illness, would you/your child have eaten any ground beef?
In the 7 days before illness, would you/your child have eaten any whole or cut beef
parts (e.g., steaks, roasts, etc.)?
In the 7 days before illness, would you/your child have eaten any processed beef (e.g.,
deli meat, sausage, jerky, pre-made dinners, etc.)?
In the 7 days before illness, would you/your child have eaten any beef made outside of
home (deli, fast food, take-out, or restaurant)?
In the 7 days before illness, would you/your child have eaten any beef made at home?
Was the beef bought fresh (refrigerated)? (Answer if Yes to Q75)
Was the beef bought frozen? (Answer if Yes to Q75)
Would you/your child, or anyone in your household, have handled raw pork in the
home?
In the 7 days before illness, would you/your child have eaten pork or any foods
containing pork?
In the 7 days before illness, would you/your child have eaten any undercooked or raw
pork?
In the 7 days before illness, would you/your child have eaten any whole or cut pork
parts (e.g., ham shank, pork chops, chitlins, etc.)?
In the 7 days before illness, would you/your child have eaten any processed pork (e.g.,
deli meat [like ham slices], bacon, sausage, etc.)?**
In the 7 days before illness, would you/your child have eaten any lamb?
In the 7 days before illness, would you/your child have eaten any non-fish seafood
(e.g., crab, shrimp, oysters, clams, etc.) that was not from a can?
In the 7 days before illness, would you/your child have eaten any non-fish seafood that
was undercooked or raw (e.g., raw oysters, clams, etc.)?
In the 7 days before illness, would you/your child have eaten any fish or fish products
(processed or unprocessed) that was not from a can?
In the 7 days before illness, would you/your child have eaten any fish that was
undercooked or raw (e.g., sushi, etc.)?
In the 7 days before illness, would you/your child have eaten any whole fish or fish
filets (unprocessed fish)?
In the 7 days before illness, would you/your child have eaten eggs or any foods
containing eggs?
In the 7 days before illness, would you/your child have eaten any eggs made away
outside of home (deli, fast food, take-out, or restaurant)?**
In the 7 days before illness, would you/your child have eaten any eggs made at home?

In the 7 days before illness, would you/your child have eaten any eggs that were runny
or raw, or uncooked foods made with raw eggs?
In the 7 days before illness, would you/your child have eaten or drank any dairy
products (e.g., milk, yogurt, cheese, ice cream, etc.)?
In the 7 days before illness, would you/your child have eaten any queso fresco, queso
blanco, or other type of Mexican-style soft cheese?
…eaten or drank any dairy products that were raw or unpasteurized (e.g., raw milk, or
cheeses, yogurts, and ice cream made from raw milk)?
In the 7 days before illness, would you/your child have eaten any fresh cantaloupe?
In the 7 days before illness, would you/your child have eaten any fresh (unfrozen)
strawberries?
In the 7 days before illness, would you/your child have eaten any other fresh
(unfrozen) berries?
In the 7 days before illness, would you/your child have eaten any fresh watermelon?
In the 7 days before illness, would you/your child have eaten any fresh apples?
In the 7 days before illness, would you/your child have eaten any fresh honeydew
melon?
In the 7 days before illness, would you/your child have eaten any fresh pineapple?
In the 7 days before illness, would you/your child have drank any unpasteurized juice
or cider?
In the 7 days before illness, would you/your child have eaten any other fruit (fresh or
frozen) or drank other fruit juices?
In the 7 days before illness, would you/your child have eaten any raw or uncooked
nuts?
In the 7 days before illness, would you/your child have eaten any fresh, raw lettuce?
In the 7 days before illness, would you/your child have eaten any fresh, raw cabbage?
In the 7 days before illness, would you/your child have eaten any fresh (unfrozen), raw
spinach?
In the 7 days before illness, would you/your child have eaten any fresh (unfrozen), raw
broccoli?
In the 7 days before illness, would you/your child have eaten any fresh, raw tomatoes?
In the 7 days before illness, would you/your child have eaten any fresh (unfrozen), raw
onions?
In the 7 days before illness, would you/your child have eaten any fresh (unfrozen), raw
carrots?
In the 7 days before illness, would you/your child have eaten any fresh, raw sprouts?
In the 7 days before illness, would you/your child have eaten any fresh (not dried)
herbs?
In the 7 days before illness, would you/your child have eaten any other vegetables
(fresh or frozen) or drank any vegetable juices?
If you are answering for an ill infant aged 1 year or younger, are they drinking infant
formula?

If you are answering for an ill infant aged 1 year or younger, are they drinking breast
milk?
If you are answering for an ill infant aged 1 year or younger, are they drinking any
other milk?
In the 7 days before illness, would you/your child have drank any water from a well?
In the 7 days before illness, would you/your child have swallowed or drank any water
directly from a natural spring, lake, pond, stream, or river?
In the 7 days before illness, would you/your child have swam in, waded in, or entered
an ocean, lake, pond, river, stream, or natural spring?
Was there a household member or a close contact with diarrhea?
In the 7 days before illness, would you/your child have had contact with dirty diapers?
In the 7 days before illness, would you/your child have lived, worked, or volunteered in
a shared living facility (e.g., dorm, nursing home, etc.)?
Would you/your child, or anyone in your house, have attended, worked, or
volunteered at a day care?
In the 7 days before illness, would you/your child have had any contact with a pet that
had diarrhea?
In the 7 days before illness, would you/your child have had any contact with a reptile
or amphibian (e.g., frog, snake, turtle, etc.)?
In the 7 days before illness, would you/your child have done any hiking, camping,
gardening, or yard work?
In the 7 days before illness, would you/your child have had any contact with animal
manure, pet feces, or compost?
In the 7 days before illness, would you/your child have visited, worked, or lived on
farm, ranch, petting zoo, or other setting that has farm animals?
Were there any live poultry (e.g., chickens, turkeys, hens, etc.)? (Answer if Yes to
Q130)
Were there any cattle, goats, or sheep? (Answer if Yes to Q130)
Were there any other farm animals (e.g., pigs, horses, etc.)? (Answer if Yes to Q130)
Site ID assigned by CDC.
Foodborne Disease.
Identification of Isolate
Date isolate taken from patient
Date of Last Modification
Is isolate confirmed
Source of isolate
Serotype/Species/Test Result
Local Case ID for Patient
Patients City of Residence
Patients State of Residence
Patients Zip code of Residence
Patients County of Residence
Date of Birth
Patients Age

Is Age reported in
Patients Sex
Patients Race
Patients Ethnicity
Comments

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

Label/Short Name
Fever
Fever date
Temperature >38°C(100.4°F)
Lower respiratory symptoms
Chest x-ray/CAT scan
Pneumonia/RDS evidence
Evaluation first date
Hospitalization
Hospital name
Hospital city
Hospital state
Hospitalization date
Discharge date
ICU admission
Mechanical ventilation
Death
Death date
Autopsy
Pathology results
HCW
HCW type
Direct patient care
Occupation
Case contact
RUI-2 or RUI-3 contact
Travel to SARS area

Travel destination
Contact classification
Nature of contact
Contact start
Contact end
Contact travel to SARS area
Contact CDC ID
Contact State ID
Contact name
Foreign travel Health Alert

Symptomatic during travel for a SARS
area
SARS suspect name
Public conveyance travel departure
Public conveyance travel departure
city
Public conveyance travel arrival city
Public conveyance transport type
Transport company
Transport number
Comment
Initial patient classification
Updated patient classification

Date updated
Laboratory Specimen 1

Lab specimen 1 collection date
Lab specimen 1 test
Lab specimen 1 source of local
testing
Lab specimen 1 result
Laboratory Specimen 2

Lab specimen 2 collection date
Lab specimen 2 test
Lab specimen 2 source of local
testing
Lab specimen 2 result
Laboratory Specimen 3

Lab specimen 3 collection date
Lab specimen 3 test
Lab specimen 3 source of local
testing
Lab specimen 3 result
Laboratory Specimen 4

Lab specimen 4 collection date

Lab specimen 4 test
Lab specimen 4 source of local
testing
Lab specimen 4 result
Laboratory Specimen 5

Lab specimen 5 collection date
Lab specimen 5 test
Lab specimen 5 source of local
testing
Lab specimen 5 result
Laboratory Specimen 6

Lab specimen 6 collection date
Lab 6 test
Lab specimen 6 source of local
testing
Lab specimen 6 result
Laboratory Specimen 7

Lab specimen 7 collection date
Lab 7 test
Lab specimen 7 source of local
testing
Lab specimen 7 result
Laboratory Specimen 8

Lab specimen 8 collection date
Lab 8 test
Lab specimen 8 source of local
testing
Lab specimen 8 result
Alternative Diagnosis
Alternative pathogen
CDC Specimen 1
Tissue specimen 1
CDC specimen 1 date
CDC Specimen 2
Tissue specimen 2
CDC specimen 2 date
CDC Specimen 3
Tissue specimen 3
CDC specimen 3 date

CDC Specimen 4
Tissue specimen 4
CDC specimen 4 date
CDC Specimen 5
Tissue specimen 5
CDC specimen 5 date
CDC Specimen 6
Tissue specimen 6
CDC specimen 6 date
CDC Specimen 7
Tissue specimen 7
CDC specimen 7 date
CDC Specimen 8
Tissue specimen 8
CDC specimen 8 date
Notes

Description
Did the patient have a fever (subjective or objective)?
If yas, date of fever onest
Was the measured temperature >38°C?
Did the patient have any lower respiratory symptoms (e.g., a cough, shortness of
breath, difficulty breathing?)?
Was a chest x-ray or CAT scan performed?
If yes, did the patient have radiographic evidence of pneumonia or respiratory distress
syndrome?
Indicate date of the first evaluation for this illness.
Was patient hospitalized for >24 hours during the course?
If yes, indicate the name of the hospital
If yes, indicate the city of the hospital
If yes, indicate the state of the hospital
Indicate date of hospitalization
Indicate date of hospital discharge
Was trhe patient ever admitted to the intensive care unit (ICU)?
Was the patient ever placed on mechanical ventilation?
Did the patient die as a result of his /her illness?
Indicate date of death
Was an autopsy performed?
Was pathology consistent with pneumonia or RDS?
Is the patient a healthcare worker?
If so, indicate type of HCW (physician, nurse/PA, lab, other [specify])
Does patient have DIRECT patient care responsibilities?
If not a HCW, list occupation.
In the 10 days prior to symptom onset did the patient have close contact with a
confirmed or probable SARS-CoV case?
In the 10 days prior to symptom onset did the patient have close contact with a person
considered an RUI-2 or RUI-3?
In the 10 days prior to symptom onset did the patient have travel to foreign or
domestic area with documented or suspected recent local transmissionof SARS cases?
If yes, list travel destinations (departure and arrival dates).
Classification of contact (RUI-2w, RUI-3, probable SARS-CoV, confirmed SARS-CoV).
Nature of contact (same household, coworker, HC environment, other).
Date contact started
Date contact ended
Did the ill contact recently travel to an area with SARS transmission (specify where)?
Contact CDC ID
Contact State ID
If CDC ID or State ID unavailable ((first, middle initial, last)
If recent foreign travel, did the patient recive a health Alert or other SARS educational
information on arrival in the U.S?

Was the patient symptomatic during the travel from a SARS affected area within 24
hours of return to the U.S or local area?
If yes, provide to the CDC the name of the SARS suspect who has traveled (enter name)
If yes, indicate public conveyance departure date
If yes, indicate public conveyance departure city
If yes, indicate public conveyance arrival city
Public conveyance transport type (airline, train, cruise, bus, auto, tour grp, other)
Name of transport company
Indicate transport number
Patient's intial classification by state of municipality (RUI-1, RUI-2, RUI-3, RUI-4, or
probable SARS-CoV, confirmed SARS-CoV)
Patient's updated classification( RUI-1, RUI-2, RUI-3, RUI-4, probable SARS-CoV,
confirmed SARS-CoV, not a case: negative serology, not a case: alternative diagnosis
accounts for illness)
Most recent updated classification
Enter specimen for each test (whole blood, serum [acute and/or convalescent],NP
swab, NP aspirate, broncheoalveolar lavage, OP swab, urine, stool, tissue [specify
tissue type])
Collection date for specimen 1
Test requested for specimen 1
Source of local testing for specimen 1
Result of lab testing for specimen 2
Enter specimen for each test (whole blood, serum [acute and/or convalescent],NP
swab, NP aspirate, broncheoalveolar lavage, OP swab, urine, stool, tissue [specify
tissue type])
Collection date for specimen 2
Test requested for specimen 2
Source of local testing for specimen 2
Result of lab testing for specimen 2
Enter specimen for each test (whole blood, serum [acute and/or convalescent],NP
swab, NP aspirate, broncheoalveolar lavage, OP swab, urine, stool, tissue [specify
tissue type])
Collection date for specimen 3
Test requested for specimen 3
Source of local testing for specimen 3
Result of lab testing for specimen 3
Enter specimen for each test (whole blood, serum [acute and/or convalescent],NP
swab, NP aspirate, broncheoalveolar lavage, OP swab, urine, stool, tissue [specify
tissue type])
Collection date for specimen 4

Test requested for specimen 4
Source of local testing for specimen 4
Result of lab testing for specimen 4
Enter specimen for each test (whole blood, serum [acute and/or convalescent],NP
swab, NP aspirate, broncheoalveolar lavage, OP swab, urine, stool, tissue [specify
tissue type])
Collection date for specimen 5
Test requested for specimen 5
Source of local testing for specimen 5
Result of lab testing for specimen 5
Enter specimen for each test (whole blood, serum [acute and/or convalescent],NP
swab, NP aspirate, broncheoalveolar lavage, OP swab, urine, stool, tissue [specify
tissue type])
Collection date for specimen 6
Test requested for specimen 6
Source of local testing for specimen 6
Result of lab testing for specimen 6
Enter specimen for each test (whole blood, serum [acute and/or convalescent],NP
swab, NP aspirate, broncheoalveolar lavage, OP swab, urine, stool, tissue [specify
tissue type])
Collection date for specimen 7
Test requested for specimen 7
Source of local testing for specimen 7
Result of lab testing for specimen 7
Enter specimen for each test (whole blood, serum [acute and/or convalescent],NP
swab, NP aspirate, broncheoalveolar lavage, OP swab, urine, stool, tissue [specify
tissue type])
Collection date for specimen 8
Test requested for specimen 8
Source of local testing for specimen 8
Result of lab testing for specimen 8
Was an alternative respiratory pathogen detected?
If yes, indicate the pathogen isolated.
List specimen(s) sent to CDC
If 'tissue', specify.
Date specimen 1 sent to CDC
List specimen(s) sent to CDC
If 'tissue', specify.
Date specimen 2 sent to CDC
List specimen(s) sent to CDC
If 'tissue', specify.
Date specimen 3 sent to CDC

List specimen(s) sent to CDC
If 'tissue', specify.
Date specimen 4 sent to CDC
List specimen(s) sent to CDC
If 'tissue', specify.
Date specimen 5 sent to CDC
List specimen(s) sent to CDC
If 'tissue', specify.
Date specimen 6 sent to CDC
List specimen(s) sent to CDC
If 'tissue', specify.
Date specimen 7 sent to CDC
List specimen(s) sent to CDC
If 'tissue', specify.
Date specimen 8 sent to CDC
Any notes needed

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

Label/Short Name
Site ID
Disease
State Lab ID
Collection Date
Last Updated
Confirmed
Specimen Source
Test Result
Local Case ID
City
State
Zip code
County
DOB
Age
Age Type
Sex
Race
Ethnicity
Comments

Description
Site ID assigned by CDC.
Foodborne Disease.
Identification of Isolate
Date isolate taken from patient
Date of Last Modification
Is isolate confirmed
Source of isolate
Serotype/Species/Test Result
Local Case ID for Patient
Patients City of Residence
Patients State of Residence
Patients Zip code of Residence
Patients County of Residence
Date of Birth
Patients Age
Is Age reported in
Patients Sex
Patients Race
Patients Ethnicity
Comments

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

Label/Short Name
Notification ID
Receiving Application
Message Profile ID

Local Subject ID
Subject Name Type

Local Record ID

Subject Type
Notification Type
Date First Submitted
Date of Report

Notification Result Status
Immediate National Notifiable
Condition
Reporting State
Reporting County
National Reporting Jurisdiction
Condition Code
Birth Date
Subject’s Sex
Race Category
Subject Address County
Subject Address State
Subject Address ZIP Code
Ethnic Group Code
Country of Birth

Census tract of case-patient
residence

Country of Usual Residence

Jurisdiction Code
Case Investigation Status Code
Investigation Date Assigned
Date of Report/Referral
Reporting Source Type Code
Reporting Source ZIP Code
Earliest Date Reported to County
Earliest Date Reported to State
Hospitalized
Admission Date
Discharge Date
Duration of hospital stay in days
Diagnosis Date
Date of Illness Onset
Illness End Date
Illness Duration
Illness Duration Units
Did the subject die from this
condition?
Deceased Date
Case Investigation Start Date
Case Outbreak indicator
Case Outbreak Name
Case Disease Imported Code
Imported Country
Imported State
Imported City

Imported County
Transmission Mode
Case Class Status Code
MMWR Week
MMWR Year
State Case ID

Date of First Report to CDC
Date First Reported PHD
Pregnancy status
Person Reporting to CDC - Name
Person Reporting to CDC - Phone
Number
Person Reporting to CDC - Title
Person Reporting to CDC - Affiliation
Legacy Case ID
Age at case investigation
Age units at case investigation
Country of Exposure or Country
Where Disease was Acquired
Note: use exposure or acquired
consistently across variables
State or Province of Exposure

City of Exposure

County of Exposure

Binational Reporting Criteria
Date of initial health exam associated
with case report "health event"
Neurological involvement?
Treatment Date
HIV Status
Had sex with a male within past 12
months?
Had sex with a female within past 12
months?
Had sex with an anonymous partner
within past 12 months?
Had sex with a person know to
him/her to be an IDU within past 12
months?
Had sex while intoxicated and/or
high on drugs within past 12 months?
Exchanged drugs/money for sex
within past 12 months?
Had sex with a person who is know
to her to be an MSM within past 12
months?
Engaged in injection drug use within
past 12 months?
During the past 12 months, which of
the following injection or noninjection drugs have been used?
Previous STD history?
Been incarcerated with past 12
months?
Have you met sex partners through
the Internet in the last 12 months?
Total number of sex partners last 12
months?

Clinician-observed lesion(s) indicative
of syphilis
Type of nontreponemal serologic test
for syphilis
Quantitative syphilis test result

Patient refused to answer questions
regarding number of sex partners
Unknown number of sex partners in
last 12 months
Date of laboratory specimen
collection
Specimen source
Date of lab result
HIV status documented through
eHARS Record Search?
eHARS Stateno
Trans_Categ (eHARS, person dataset)
Case sampled for enhanced
investigation?
Method of case detection
Type of treponemal serologic test for
syphilis
Count
Event date

Datetype

NETSS version
STD-Associated Lab Tests
STD-Associated Lab Results
Injection or non-injection drugs use
indicator
Nontreponemal serologic syphilis
test (quantitative)

Nontreponemal serologic syphilis
test (qualitative)
Qualitative treponemal serologic
syphilis test result
Neurological manifestations

Description
The unique identifier for the notification record
CDC's PHIN Common Data Store (CDS) is the Receiving Application for this message.
First instance is the reference to the structural specification used to validate the
message.
Second instance is the reference to the PHIN Message Mapping Guide from which the
content is derived.
The local ID of the subject/entity.
Name is not requested by the program, but the Patient Name field is required to be
populated for the HL7 message to be valid. Have adopted the HL7 convention for
processing a field where the name has been removed for de-identification purposes.
Sending system-assigned local ID of the case investigation with which the subject is
associated.
Note: The local record ID should be the unique identifier for the case being reported.
Type of subject for the notification. "Person," "Place/Location," or "Non-Person Living
Subject" are the appropriate subject types for Notifications to CDC.
Type of notification. Notification types are "Individual Case," "Environmental,"
"Summary," and "Laboratory Report".
Date/time the notification was first sent to CDC. This value does not change after the
original notification.
Date/time this version of the notification was sent. It will be the same value as
NOT103 for the original notification. For updates, this is the update/send date/time.
Status of the notification.
Does this case meet the criteria for immediate (extremely urgent or urgent)
notification to CDC?
State reporting the notification.
County reporting the notification.
National jurisdiction reporting the notification to CDC.
Condition or event that constitutes the reason the notification is being sent
Date of birth in YYYYMMDD format
Subject’s current sex
Field containing one or more codes that broadly refer to the subject’s race(s).
County of residence of the subject
State of residence of the subject
ZIP Code of residence of the subject
Based on the self-identity of the subject as Hispanic or Latino
Country of Birth

Census tract where the address is located is a unique identifier associated with a small
statistical subdivision of a county. Census tract data allows a user to find population
and housing statistics about a specific part of an urban area. A single community may
be composed of several census tracts.
Where does the person usually* live (defined as their residence)
*For the definition of ‘usual residence’ refer to CSTE position statement # 11-SI-04
titled “Revised Guidelines for Determining Residency for Disease Reporting” at
http://www.cste.org/ps2011/11-SI-04.pdf .
Identifier for the physical site from which the notification is being submitted.
Status of the investigation
Date the investigator was assigned to this investigation.
Date the event or illness was first reported by the reporting source (physician or lab
reported to the local/county/state health department).
Type of facility or provider associated with the source of information sent to Public
Health.
ZIP Code of the reporting source for this case.
Earliest date reported to county public health system
Earliest date reported to state public health system
Was subject hospitalized because of this event?
Subject’s admission date to the hospital for the condition covered by the investigation.
Subject's discharge date from the hospital for the condition covered by the
investigation.
Subject's duration of stay at the hospital for the condition covered by the investigation.
Date of diagnosis of condition being reported to public health system
Date of the beginning of the illness. Reported date of the onset of symptoms of the
condition being reported to the public health system
Time at which the disease or condition ends.
Length of time this subject had this disease or condition.
Unit of time used to describe the length of the illness or condition.
Did the subject die from this illness or complications of this illness?
If the subject died from this illness or complications associated with this illness,
indicate the date of death
The date the case investigation was initiated.
Denotes whether the reported case was associated with an identified outbreak.
A state-assigned name for an indentified outbreak.
Indication of where the disease/condition was likely acquired.
If the disease or condition was imported, indicates the country in which the disease
was likely acquired.
If the disease or condition was imported, indicates the state in which the disease was
likely acquired.
If the disease or condition was imported, indicates the city in which the disease was
likely acquired.

If the disease or condition was imported, contains the county of origin of the disease or
condition.
Code for the mechanism by which disease or condition was acquired by the subject of
the investigation.
Status of the case/event as suspect, probable, confirmed, or not a case per CSTE/CDC/
surveillance case definitions.
MMWR Week for which case information is to be counted for MMWR publication.
MMWR Year (YYYY) for which case information is to be counted for MMWR
publication.
States use this field to link NEDSS investigations back to their own state investigations.
Note: This may be any state-assigned ID number for the case; may be different than
INV168, which is the system-assigned unique identified for the 'case' of disease being
reported.
Date the case was first reported to the CDC
Earliest date the case was reported to the public health department whether at the
local, county, or state public health level.
Indicates whether the subject was pregnant at the time of the event.
Name of the person who is reporting the case to the CDC
Phone Number of the person who is reporting the case to the CDC
Job title / description of the person reporting the case to the CDC
Affiliated Facility of the person reporting the case to the CDC
CDC uses this field to link current case notifications to case notifications submitted by a
previous system (NETSS, STD-MIS, etc.)
Subject age at time of case investigation
Subject age units at time of case investigation
Indicates the country in which the disease was potentially acquired.

Indicates the state in which the disease was potentially acquired.
Business Rule: If Country of exposure was US, populate with US State. If Country of
exposure was Mexico, populate with Mexican State. If country of exposure was
Canada, populated with Canadian Province. For all other countries, leave null.
Indicates the city in which the disease was potentially acquired.
Business Rule: If country of exposure is US, populate with US city. For all other cities,
can be populated but not required.
Note: Since value set only includes US cities, would allow states to populate the CWE
9th component with another city.

Indicates the county in which the disease was potentially acquired.
Business Rule: If country of exposure is US, populate with US county. Otherwise, leave
null.
For cases meeting the binational criteria, select all the criteria which are met
Date of earliest healthcare encounter/visit /exam associated with this event/case
report. May equate with date of exam or date of diagnosis.
If event = some stage of syphilis, does the patient have neurologic involvement based
on current case definition?
Date treatment initiated for the condition that is the subject of this case report.
Documented or self-reported HIV status at the time of event.
Had sex with a male within past 12 months?
Had sex with a female within past 12 months?
Had sex with an anonymous partner within past 12 months?
Had sex with a person known to him/her to be an IDU within past 12 months?

Had sex while intoxicated and/or high on drugs within past 12 months?

Exchanged drugs/money for sex within past 12 months?
Had sex with a person who is known to her to be an MSM within past 12 months?
NOTE: For women only.
Engaged in injection drug use within past 12 months?
During the past 12 months, which of the following injection or non-injection drugs
have been used?
Does the patient have a history of ever having had an STD prior to the condition
reported in this case report?
Been incarcerated within past 12 months?
Did the patient use an online computer site to exchange messages by typing them
onscreen to engage in conversation with other visitors to the site for the purpose of
having sex?
Total number of sex partners that the case patient has had in the last 12 months. Total
partners equal the sum of all male, female, and transgender partners during the
period.

If condition = any stage of syphilis, report anatomic site(s) of clinician-observed
lesion(s) (e.g., chancre, rash, condyloma lata) at time of initial exam or specimen
collection. Mark all that apply.
What type of non-treponemal serologic test for syphilis was performed on specimen
collected to support case patient's diagnosis of syphilis?
If the test performed provides a quantifiable result, provide quantitative result (e.g. if
RPR is positive, provide titer, e.g. 1:64)
Example: If titer is 1:64, enter 64; if titer is 1:1024, enter 1024.
Patient refused to answer questions regarding number of sex partners

Unknown number of sex partners in last 12

months

Date of collection of initial laboratory specimen used for diagnosis of health event
reported in this case report. PREFERRED date for assignment of MMWR week. First
date in hierarchy of date types associated with case report/event.
Anatomic site or specimen type from which positive lab specimen was collected.
Date result sent from Reporting Laboratory.
Was the HIV status of this case investigated through search of eHARS?
Stateno from eHARS registry for HIV+ cases.
Mode of exposure from eHARS for HIV+ cases.
Was this case selected by reporting jurisdiction for enhanced investigarion?
How case patient first came to the attention of the health department for this
condition
What type of treponemal serologic test for syphilis was performed on specimen
collected to support case patient's diagnosis of syphilis?
represents # of cases reported in this ‘record’; supports aggregate-(when >1) or casespecific (when=1) reporting.
date of disease in YYMMDD format. This date depends upon how case dates are
assigned in the STD program. i.e., date could be the onset of symptoms date, diagnosis
date, laboratory result date, date case first recognized and/or reported to STD
program, or date case reported to CDC.
describes the type of date provided in Event date

What version of the NETSS record layout are you providing?
STD-Associated Lab Tests
STD-Associated Lab Results
Injection or non-injection drug use indicator
If the test performed provides a quantifiable result, provide quantitative result (e.g.
if RPR is positive, provide titer, e.g. 1:64)
Example: If titer is 1:64, enter 64; if titer is 1:1024, enter 1024.

Qualitative test result of STD123 Nontreponemal serologic syphilis test result
(quantitative)
If the test performed provides a qualitative result, provide qualitative result, e.g.
weakly reactive.
Neurological manifestations of disease

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

PHVS_NameType_HL7_2x

PHVS_NotificationSectionHeader_CDC
PHVS_NotificationSectionHeader_CDC

PHVS_ResultStatus_NND
PHVS_NationalReportingJurisdiction_NND
PHVS_State_FIPS_5-2
PHVS_County_FIPS_6-4
PHVS_NationalReportingJurisdiction_NND
PHVS_NotifiableEvent_Disease_Condition_CDC_NNDSS

PHVS_RaceCategory_CDC
PHVS_County_FIPS_6-4
PHVS_State_FIPS_5-2
PHVS_EthnicityGroup_CDC_Unk
PHVS_CountryofBirth_CDC

PHVS_CountryofBirth_CDC

PHVS_CaseInvestigationStatus_NND

PHVS_ReportingSourceType_NND

PHVS_YesNoUnknown_CDC

PHVS_AgeUnit_UCUM
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_DiseaseAcquiredJurisdiction_NETSS
PHVS_Country_ISO_3166-1
PHVS_State_FIPS_5-2
PHVS_City_USGS_GNIS

PHVS_County_FIPS_6-4
PHVS_CaseTransmissionMode_NND
PHVS_CaseClassStatus_NND

PHVS_YesNoUnknown_CDC

PHVS_AgeUnit_UCUM_NETSS
PHVS_CountryofBirth_CDC

PHVS_State_FIPS_5-2

PHVS_BinationalReportingCriteria_CDC

New Value Set
PHVS_Neurological_involvement_CDC
New Value Set
PHVS_HIVStatus_CDC
New Value Set
PHVS_YNRD_CDC
New Value Set
PHVS_YNRD_CDC
New Value Set
PHVS_YNRD_CDC
New Value Set
PHVS_YNRD_CDC
New Value Set
PHVS_YNRD_CDC
New Value Set
PHVS_YNRD_CDC
New Value Set
PHVS_YNRD_CDC
New Value Set
PHVS_YNRD_CDC
New Value Set
PHVS_DrugsUsed_CDC
New Value Set
PHVS_PreviousSTDhistory_CDC
New Value Set
PHVS_YNRD_CDC
New Value Set
PHVS_YNRD_CDC

New Value Set
PHVS_Clinician-observed lesions_CDC
New Value Set
PHVS_nontreponemalserologictest_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

New Value Set
PHVS_SpecimenSource_CDC
PHVS_YesNoUnknown_CDC

New Value Set
PHVS_TransCateg_CDC
PHVS_YesNoUnknown_CDC
New Value Set
PHVS_DetectionMethod_CDC
New Value Set
PHVS_treponemalserologic_CDC
##### Default=00001 for case-specific records where a single case is
represented by data record.
YYMMDD Unknown=999999

1=Onset Date 2=Date of diagnosis 3=Date of laboratory result 4=Date
of first report to coummunity health system 5=State/MMWR report
date 9=Unknown
i.e. Version 3 (January 2011) 03=Version 3
STD-Associated RCMT Lab Tests (OBX-3)
STD-Associated RCMT Lab Results (OBX-5)
New Value Set
PHVS_YNRD_CDC
New Value Set
PHVS_QuantitativeSyphilisTestResult_STD

New Value Set
PHVS_LabTestReactivity_NND
New Value Set
PHVS_LabTestResultQualitative_NND

Label/Short Name
AgClinic
AgClinicTestType
AgeMnth
AgeYr
AgSphl

AgSphlTestType
BioId
BloodyDiarr
Diarrhea
DtAdmit2
DtDisch2
DtEntered
DtRcvd
DtRptComp
DtSpec
DtUSDepart
DtUSReturn
EforsNum
Fever
HospTrans
HUS
Immigrate
Interview
LabName
LocalID
OtherCdcTest
OtherClinicTest
OtherClinicTestType
OtherSphlTest
OtherSphlTestType
OutbrkType
PatID
PcrCdc
PcrClinic
PcrClinicTestType

PcrSphl
PersonID
ResultID
RptComp
SentCDC
SLabsID
SpecSite
StecH7
StecHAg
StecNM
StecO157
StecOAg
StecStx
StLabRcvd

TravelDest
TravelInt
PulseNet Key
Date of interview
Respondent
Other Respondent
City of residence
Month of birth
Year of birth
Hispanic or Latino
Total days ill
Still ill
Diarrhea
Diarrhea onset
Bloody stool
Still hospitalized
HUS
Food handler
Daycare worker
Foods at home
Foods away from home
Handled raw ground beef
Ground beef
Ground beef at home
Pink ground beef at home
Ground beef at home purchase
location

Ground beef at home purchase date
Ground beef brand
Ground beef bulk
Ground beef patties
Ground beef other
Ground beef unknown purchase form
Home ground beef size
Percent lean
Fresh ground beef
Frozen ground beef
Unknown fresh/frozen ground beef
Ground beef away from home
Gound beef away from home
location
Pink ground beef away
Hamburger
Meatball
Meatloaf
Taco
Ground beef in a dish
Other form of ground beef outside
home
Specify other form of ground beef
Steak
Steak at home
Pink steak at home
Steak at home purchase location
Steak at home purchase date
Steak brand
Steak consumed as steak
Steak consumed as stew
Steak consumed as roast
Unknown steak type
Steak consumed as other
Specify how steak was consumed
Steak away from home
Steak away from home location
Steak away from home dates
Pink steak away
Pink steak away as steak
Pink steak away as stew
Pink steak away as roast

Pink steak away as other product
Specify how other pink steak was
consumed
Bison
Bison at home
Pink bison at home
Bison purchase location
Bison purchase date
Bison at home brand
Bison away from home
Bison away location
Bison away date
Pink bison away from home
Wild game
Dried meat
Pepperoni
Salami
Sausage
Other dried meat
Typle of other dried meat
Jerky
Raw milk
Raw cheese
Raw cheese type
Raw cheese location
Raw cheese date
Raw ice cream
Raw juice
Lettuce
Lettuce at home
Lettuce at home purchase location
Lettuce at home purchase date
Lettuce at home brand
Loose lettuce at home
Prepackaged lettuce at home
Unknown packaging of lettuce at
home
Lettuce away from home
Lettuce away from home location
Mesclun lettuce
Mesclun lettuce at home

Mesclun lettuce at home purchase
location
Mesclun lettuce at home purchase
date
Mesclun lettuce at home brand
Loose mesclun lettuce at home
Prepackaged mesclun lettuce at
home
Unknown packaging of mesclun
lettuce at home
Mesclun lettuce away from home
Mesclun lettuce away from home
location
Iceberg lettuce
Iceberg lettuce at home
Iceberg lettuce at home purchase
location
Iceberg lettuce at home purchase
date
Iceberg lettuce at home brand
Loose iceberg lettuce at home
Prepackaged iceberg lettuce at home
Unknown packaging of iceberg
lettuce at home
Iceberg lettuce away from home
Iceberg lettuce away from home
location
Romaine lettuce
Romaine lettuce at home
Romaine lettuce at home purchase
location
Romaine lettuce at home purchase
date
Romaine lettuce at home brand
Loose romaine lettuce at home
Prepackaged romaine lettuce at
home
Unknown packaging of romaine
lettuce at home
Romaine lettuce away from home
Romaine lettuce away from home
location
Red leaf lettuce

Red leaf lettuce at home
Red leaf lettuce at home purchase
location
Red leaf lettuce at home purchase
date
Red leaf lettuce at home brand
Loose red leaf lettuce at home
Prepackaged red leaf lettuce at home
Unknown packaging of red leaf
lettuce at home
Red leaf lettuce away from home
Red leaf lettuce away from home
location
Spinach
Spinach at home
Spinach at home purchase location
Spinach at home purchase date
Spinach at home brand
Loose spinach at home
Prepackaged spinach at home
Unknown packaging of spinach at
home
Spinach away from home
Spinach away from home location
Other leafy greens
Other leafy greens at home
Other leafy greens at home purchase
location
Other leafy greens at home purchase
date
Other leafy greens at home brand
Loose other leafy greens at home
Prepackaged other leafy greens at
home
Unknown packaging of other leafy
greens at home
Other leafy greens away from home
Other leafy greens away from home
location
Sprouts
Sprouts at home
Sprouts at home purchase locations
Sprouts at home purchase date

Sprouts at home brand
Sprouts away from home
Sprouts away from home location
Sprouts way from home type
Petting zoo
Farm with livestock
Farm and Feed store
Pet store
Fair
Pet treats
Animal droppings
Daycare
Any travel
Domestic travel
Domestic travel start date
Domestic travel end date
International travel
International travel start date
International travel end date
Group meals
Institution
Institution location
Source of drinking water
Site ID
Disease
State Lab ID
Collection Date
Last Updated
Confirmed
Specimen Source
Test Result
Local Case ID
City
State
Zip code
County
DOB
Age

Age Type
Sex
Race
Ethnicity
Comments

Description
For possible E. coli cases: What was the result of specimen testing for Shiga toxin using
an antigen-based test (e.g.EIA or lateral flow) at a clinical laboratory?
Name of antigen-based test used at clinical laboratory
Age of case-patient in months if patient is <1yr
Age of case-patient in years
For possible E. coli cases: What was the result of specimen testing for Shiga toxin using
an antigen-based test (e.g.EIA or lateral flow) at a state public health laboratory?
Name of antigen-based test used at state public health laboratory
Was the pathogen identified by culture?
Did the case-patient have bloody diarrhea (self reported) during this illness?
Did the case-patient have diarrhea (self-reported) during this illness?
Date of hospital admission for second hospitalization for this illness
Date of hospital discharge for second hospitalization for this illness
Date case was entered into site's database
Date case-pateint's specimen was received in laboratory for initial testing
Date case report form was completed
Case-patient's specimen collection date
If case-patient patient traveled internationally, date of departure from the U.S.
If case-patient traveled internationally, date of return to the U.S.
CDC FDOSS outbreak ID number
Did the case-patient have fever (self-reported) during this illness?
If case-patient was hospitalized, was s/he transferred to another hospital?
Did case patient have a diagnosis of HUS?
Did case-patient immigrate to the U.S.? (within 7 days of illness onset)
Was the case-patient interviewed by public health (i.e. state or local health
department) ?
Name of submitting laboratory
Ccase-patient's medical record number
What was the result of specimen testing for Shiga toxin using another test at the CDC?
What was the result of specimen testing for Shiga toxin using another test at a clinical
laboratory
Name of other test used at a clinical laboratory
What was the result of specimen testing for Shiga toxin using another test at a state
public health laboratory?
Name of other test used at a state public health laboratory
Type of outbreak that the case-patient was part of
Case-patient identification number
What was the result of specimen testing for Shiga toxin using PCR at CDC?
What was the result of specimen testing for Shiga toxin using PCR at a clincal
laboratory?
Name of PCR assay used

What was the result of specimen testing for Shiga toxin using PCR at a state public
health laboratory?
Unique identification number for person or patient
Unique identifier for laboratory result
Is all of the information for this case complete?
Was specimen or isolate forwarded to CDC for testing or confirmation?
State lab identification number
Case patient's specimen collection source
Was it H7 antigen positive?
What was the H-antigen number?
Was the isolate non-motile?
Was it O157 positive?
What was the O-antigen number?
Was E. coli Shiga toxin-producing?
Was the isolate sent to a state public health laboratory? (Answer 'Yes' if it was sent to
any state lab, even if it was sent to a lab outside of the case's state of residence)
If case-patient traveled internationally, to where did they travel?
Did the case patient travel internationally? (within 7 days of onset)
Identification tag in PulseNet database
Date questionnaire administered to case
Individual who was interviewed
If case, parent, or spouse not interviewed, then who was?
City where patient resides
Month when patient was born
Year when patient was born
Is the patient of Hispanic or Latino origin
Length of patient's illness in days
Is the patient still ill
Patient experienced 3 or more loose stools in 24-hour period
Date patient first expierenced 3 or more loose stools
Patient experienced blood in stool
Is the patient still hospitalizaed
Patient diagnosed by doctor with HUS or kidney failure
Patient works as a food handler at dining establishment
Patient works in a daycare facility
List of locations where foods eaten at home were purchased
List of locations where foods were eaten outside of the home
Patient handled raw ground beed (even if not consumed) in 7 days prior to illness
onset
Patient consumed ground beef in 7 days prior to illness onset
Patient consumed ground beef at home in 7 days prior to illness onset
Patient consumed red or pink ground beef at home in 7 days prior to illness onset
Location(s) where ground beef consumed at home in 7 days prior to illness onset was
purchased

Date(s) when ground beef consumed at home in 7 days prior to illness onset was
purchased
Brand(s) of ground beef eaten at home in 7 days prior to illness onset
Ground beef eaten at home was purchased in bulk
Ground beef eaten at home was purchased in pre-formed patties
Ground beef eaten at home was purchased in other form
Patient unable to recall form in which ground beef eaten at home was purchased
Size in which ground beef consumed at home was purchased
Percentage lean of ground beef eaten at home
Ground beef eaten at home was purchased fresh
Ground beef eaten at home was purchased frozen
Patient unable to recall if ground beef consumed at home was purchased fresh or
frozen
Patient consumed ground beef away from home in 7 days prior to illness onset
Location(s) where ground beef consumed away from home
Patient consumed red or pink ground beef away from home
Ground beef eaten outside the home as hamburger
Ground beef eaten outside the home as meatball
Ground beef eaten outside the home as meatloaf
Ground beef eaten outside the home in a taco
Ground beef eaten in a dish (ex. casserole) outside the home
Ground beef eaten outside the home in form other than hamburger, meatball,
meatloaf, taco, or in a dish
Other type of ground beef eaten outside the home
Patient consumed steak in 7 days prior to illness onset
Patient consumed steak at home in 7 days prior to illness onset
Steak consumed at home was pink or read
Location(s) where steak consumed at home was purchased
Date(s) when steak consumed at home was purchased
Brand(s) of steak eaten at home
Steak was consumed as steak
Steak was consumed in a stew
Steak was consumed as a roast
Patient unable to recall how steak was consumed
Steak was consumed in form other than steak, stew, roast
If steak was consumed in other form, then specify
Patient consumed steak away from home in 7 days prior to illness onset
Location(s) where steak was consumed away from home
Date(s) when steak was consumed away from home
Patient consumed red or pink steak away from home
Patient consumed red or pink steak away from home as steak
Patient consumed red or pink steak away from home as stew
Patient consumed red or pink steak away from home as a roast

Patient consumed red or pink steak away from home in form other than steak, stew, or
roast
Specify if 'Other' red or pink steak was reported
Patient consumed bison in the 7 days prior to illness onset
Patient consumed bison at home in the 7 days prior to illness onset
Patient consumed red or pink bison at home
Location(s) where ground beef consumed at home was purchased
Date(s) when bison consumed at home was purchased
Brand of bison purchased for home consumption
Patient consumed bison away from home in 7 days prior to illness onset
Location(s) where bison was consumed outside the home
Date(s) when bison was consumed outside the home
Bison eaten outside the home was red or pink
Patient consumed wild game in the 7 days before illness onset
Patient consumed dried meat in the 7 days before illness onset
Patient consumed dried meat that was pepperoni
Patient consumed dried meat that was salami
Patient consumed dried meat that was sausage
Patient consumed dried meat that was not pepperoni, salami, or sausage
Specify other type of dried meat consumed
Patient consumed jerkey of any type in the 7 days before illness onset
Patient consumed raw milk in the 7 days before illness onset
Patient consumed cheese made with raw milk in the 7 days before illness onset
Type of raw milk cheese consumed
Location(s) where raw milk cheese was purchased
Date(s) when raw milk cheese was purchased
Patient consumed ice cream made with raw milk in the 7 days before illness onset
Patient consumed raw or unpasteurized juice or cide in the 7 dayse before illness onset
Patient consumed lettuce of any kind in the 7 days before illness onset
Patient consumed lettuce of any kind at home in the 7 days before illness onset
Location(s) where lettuce consumed at home was purchased
Date(s) when lettuce consumed at home was purchased
Brand(s) of lettuce purchased for home consumption
Patient consumed loose lettuce of any kind in the 7 days before illness onset
Patient consumed prepackaged lettuce of any kind in the 7 days before illness onset
Patient unable to recall how lettuce consumed at home was packaged
Patient consumed lettuce of any kind away from home in the 7 days before illness
onset
Location(s) where the lettuce was consumed away from home
Patient consumed mesclun lettuce in the 7 days before illness onset
Patient consumed mesclun lettuce at home in the 7 days before illness onset

Location(s) where mesclun lettuce consumed at home was purchased
Date(s) when mesclun lettuce consumed at home was purchased
Brand(s) of mesclun lettuce consumed at home
Patient consumed loose mesclun lettuce at home
Patient consumed prepackaged mesclun lettuce at home
Patient unable to recall how mesclun lettuce consumed at home was purchased
Patient consumed mesclun lettuce away from home in the 7 days before illness onset
Location(s) where the mesclun lettuce was consumed away from home
Patient consumed iceberg lettuce in the 7 days before illness onset
Patient consumed iceberg lettuce at home in the 7 days before illness onset
Location(s) where iceberg lettuce consumed at home was purchased
Date(s) when iceberg lettuce consumed at home was purchased
Brand(s) of iceberg lettuce consumed at home
Patient consumed iceberg mesclun lettuce at home
Patient consumed prepackaged iceberg lettuce at home
Patient unable to recall how iceberg lettuce consumed at home was purchased
Patient consumed iceberg lettuce away from home in the 7 days before illness onset
Location(s) where the iceberg lettuce was consumed away from home
Patient consumed romaine lettuce in the 7 days before illness onset
Patient consumed romaine lettuce at home in the 7 days before illness onset
Location(s) where romaine lettuce consumed at home was purchased
Date(s) when romaine lettuce consumed at home was purchased
Brand(s) of romaine lettuce consumed at home
Patient consumed loose romaine lettuce at home
Patient consumed prepackaged romaine lettuce at home
Patient unable to recall how romaine lettuce consumed at home was purchased
Patient consumed romaine lettuce away from home in the 7 days before illness onset
Location(s) where the romaine lettuce was consumed away from home
Patient consumed red leaf lettuce in the 7 days before illness onset

Patient consumed red leaf lettuce at home in the 7 days before illness onset
Location(s) where red leaf lettuce consumed at home was purchased
Date(s) when red leaf lettuce consumed at home was purchased
Brand(s) of red leaf lettuce consumed at home
Patient consumed loose red leaf lettuce at home
Patient consumed prepackaged red leaf lettuce at home
Patient unable to recall how red leaf lettuce consumed at home was purchased
Patient consumed red leaf lettuce away from home in the 7 days before illness onset
Location(s) where the red leaf lettuce was consumed away from home
Patient consumed spinach in the 7 days before illness onset
Patient consumed spinach at home in the 7 days before illness onset
Location(s) where spinach consumed at home was purchased
Date(s) when spinach consumed at home was purchased
Brand(s) of spinach consumed at home
Patient consumed spinach at home
Patient consumed prepackaged spinach at home
Patient unable to recall how spinach consumed at home was purchased
Patient consumed spinach away from home in the 7 days before illness onset
Location(s) where the spinach was consumed away from home
Patient consumed other leafy greens in the 7 days before illness onset
Patient consumed other leafy greens at home in the 7 days before illness onset
Location(s) where other leafy greens consumed at home was purchased
Date(s) when other leafy greens consumed at home was purchased
Brand(s) of other leafy greens consumed at home
Patient consumed other leafy greens at home
Patient consumed prepackaged other leafy greens at home
Patient unable to recall how other leafy greens consumed at home was purchased
Patient consumed other leafy greens away from home in the 7 days before illness
onset
Location(s) where the other leafy greens was consumed away from home
Patient consumed sprouts of any kind in the 7 days before illness onset
Patient consumed sprouts of any kind at home in the 7 days before illness onset
Location(s) where sprouts consumed at home were purchased
Date(s) when sprouts consumed at home were purchased

Brand(s) of sprouts consumed at home
Patient consumed sprouts of any kind away from home in the 7 days before illness
onset
Location(s) where sprouts were consumed away from home
Type of sprouts consumed outside the home
Patient visited a petting zoo in the 7 days before illness onset
Patient visited, worked, or lived on a farm with livestock in the 7 days before illness
onset
Patient visited an agricultural 'Farm and Feed' store in the 7 days before illness onset
Patient visited a pet store, swap meets, or other places where animals/birds are sold or
shown in the 7 dayse before illness onset
Patient visited a county or state fair, 4-H event, or similar even with animals in the 7
days before illness onset
Patient had contact with pet treats or chews in the 7 days before illness onset
Patient had contact with dried animal droppings or pellets in the 7 days before illness
onset
Patient attended or had contact with a daycare facility in the 7 days before illness
onset
Patient spent all or some of the 7 days before illness onset outside of their state of
residence
Postal code abbreviation of state(s) where patient traveled
Domestic travel start date
Domestic travel end date
Countries visited in the 7 days before illness onset
International travel start date
International travel end date
Patient attended a group meal in the 7 days before illness onset
Patient visited, lives, or works in an institutional home (jail, nursing home, etc.)
Location of institution where patient visits, lives, or works
Main source of drinking water for patient during the 7 days before illness onset
Site ID assigned by CDC.
Foodborne Disease.
Identification of Isolate
Date isolate taken from patient
Date of Last Modification
Is isolate confirmed
Source of isolate
Serotype/Species/Test Result
Local Case ID for Patient
Patients City of Residence
Patients State of Residence
Patients Zip code of Residence
Patients County of Residence
Date of Birth
Patients Age

Is Age reported in
Patients Sex
Patients Race
Patients Ethnicity
Comments

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

Self; Parent; Spouse; Other

12-Jan
Hispanic; Non-Hispanic; Unknown
Yes; No
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
Yes; No
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown

Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown

Yes; No
Yes; No
Yes; No
Yes; No
Number of pounds; Unknown
Percentage; Unknown
Yes; No
Yes; No
Yes; No
Yes; No; Maybe; Unknown

Yes; No; Maybe; Unknown
Yes; No
Yes; No
Yes; No
Yes; No
Yes; No
Yes; No

Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown

Yes; No
Yes; No
Yes; No
Yes; No
Yes; No
Yes; No; Maybe; Unknown

Yes; No; Maybe; Unknown
Yes; No
Yes; No
Yes; No

Yes; No

Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown

Yes; No; Maybe; Unknown

Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
Yes; No
Yes; No
Yes; No
Yes; No
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown

Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown

Yes; No
Yes; No
Yes; No
Yes; No; Maybe; Unknown

Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown

Yes; No
Yes; No
Yes; No
Yes; No; Maybe; Unknown

Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown

Yes; No
Yes; No
Yes; No
Yes; No; Maybe; Unknown

Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown

Yes; No
Yes; No
Yes; No
Yes; No; Maybe; Unknown

Yes; No; Maybe; Unknown

Yes; No; Maybe; Unknown

Yes; No
Yes; No
Yes; No
Yes; No; Maybe; Unknown

Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown

Yes; No
Yes; No
Yes; No
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown

Yes; No
Yes; No
Yes; No
Yes; No; Maybe; Unknown

Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown

Yes; No; Maybe; Unknown

Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown

Yes; No; Maybe; Unknown
Yes; No; Maybe; Unknown
City/municipal; Well; Bottled; Unknown

Label/Short Name
DAYCARE
FACNAME
NURSHOME
NHNAME
SYNDRM
SPECSYN
SPECIES
OTHBUG1
STERSITE
OTHSTER
DATE
NONSTER
UNDERCOND
COND
OTHMALIG
OTHORGAN
OTHILL
OTHOTHSPC
Specify Internal Body Site
Other Prior Illness 2
Other Prior Illness 3
Other Nonsterile Site
INSURANCE
INSURANCEOTH
WEIGHTLB
WEIGHTOZ
WEIGHTKG
HEIGHTFT
HEIGHTIN
HEIGHTCM
WEIGHTUNK
HEIGHTUNK
SURGERY
SURGDATE
DELIVERY
BABYDATE
GASCOND

Description
If <6 years of age, is the patient in daycare?
Name of the daycare facility.
Does the patient reside in a nursing home or other chronic care facility?
Name of the nursing home or chronic care facility.
Types of infection that are caused by the organism. This is a multi-select field.
Other infection that is caused by the organism.
Bacterial species that was isolated from any normally sterile site.
Other bacterial species that was isolated from any normally sterile site.
Sterile sites from which the organism was isolated. This is a multi-select field.
Other sterile site from which the organism was isolated.
Date the first positive culture was obtained. (This is considered diagnosis date.)
Nonsterile sites from which the organism was isolated. This is a multi-select field.
Did the patient have any underlying conditions?
Underlying conditions that the subject has. This is a multi-select field.
Other malignancy that the subject had as an underlying condition.
Detail of the organ transplant that the subject had as an underlying condition.
Other prior illness that the subject had as an underlying condition.
Another Bacterial Species not listed in the Other Bacterial Species drop-down list.
Internal Body Site where the organism was located.
Other prior illness that the subject had as an underlying condition.
Other prior illness that the subject had as an underlying condition.
Other nonsterile site from which the organism was isolated.
Patient's type of insurance (multi-selection).
Patient's other type of insurance.
Weight of the patient in pounds.
Weight of the patient in ounces.
Weight of the patient in kilograms.
Height of the patient in feet.
Height of the patient in inches.
Height of the patient in centimeters.
Indicator that the weight of the patient is unknown.
Indicator that the height of the patient is unknown.
Did the patient have surgery?
Date of the surgery
Did the patient have a baby (vaginal or C-section)?
Date of the baby's delivery
Did the patient have other prior conditions? This is a multi-select field.

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
TBD
TBD
TBD
TBD

TBD
PHVS_YesNoUnknown_CDC
TBD

TBD

TBD

PHVS_TrueFalse_CDC
PHVS_TrueFalse_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
TBD

Label/Short Name
Clinically Compatible Illness
History of Tick Bite
Eschar
Immunosuppressive Condition
Adult respiratory distress syndrome
Disseminated Intravascular
Coagulation
Meningitis
Encephalitis
Renal Failure
Othere life threatening complication
Laboratory Name
Laboratory State
Acute Serology Collection Date
Acute IFA IgG Result
Acute IFA IgG Titer
Acute IFA IgM Result
Acute IFA IgM Titer
Acute Serology, Other Test
Acute Serology Result, Other Test
Acute Serology Numeric Result,
Other Test
Convalescent Serology Collection
Date
Convalescent IFA IgG Result
Convalescent IFA IgG Titer
Convalescent IFA IgM Result
Convalescent IFA IgM Titer
Convalescent Serology, Other Test
Convalescent Serology Result, Other
Test
Convalescent Serology Numeric
Result, Other Test
PCR
Morulae
Immunostain
Culture
Fourfold

Other Etiologic Agent

Description
Did this case have a clinically compatible illness as defined by the latest CSTE case
definitions?
Was there a history of a tick bite within 14 days of onset?
Was there an eschar, or tache noire, present?
If the case reports an immunosuppressive condition, then indicate condition here
Did the case report adult respiratory distress syndrome during the course of this
illness?
Did the case report disseminated intravascular coagulation during the course of this
illness?
Did the case report meningitis during the course of this illness?
Did the case report encephalitis during the course of this illness?
Did the case report renal failure during the course of this illness?
If the case reported another life threatening complication during the course of this
illness, then list it here
Indicate the name of the laboratory which supplied results supporting the current CSTE
case definitions.
Indicate the state where the laboratory is located
If an acute serology was collected, then list the date of collection
If performed, was the acute IFA IgG positive
If performed, what was the reciprocal titer of the acute IFA IgG
If performed, was the acute IFA IgM positive
If performed, what was the reciprocal titer of the acute IFA IgM
If performed, what was the name of another acute serology test
If performed, was this other acute serology test positive
If performed, what was the numeric result of the other serology test
If an convalescent serology was collected, then list the date of collection
If performed, was the convalescent IFA IgG positive
If performed, what was the reciprocal titer of the convalescent IFA IgG
If performed, was the convalescent IFA IgM positive
If performed, what was the reciprocal titer of the convalescent IFA IgM
If performed, what was the name of another convalescent serology test
If performed, was this other convalescent serology test positive
If performed, what was the numeric result of the other serology test
If performed, was the polymerase chain reaction assay positive
If performed, were morulae visualized during microscopy
If performed, were antibodies detected using immunohistochemistry during
microscopy
If performed, was the etiologic agent isolated from culture
If paired sera were collected, was there a fourfold change in titer between acute and
convalescent

If etiologic agent was unusual, then indicate the species here (for example, R. africae)

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_State_FIPS_5-2
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

Label/Short Name
Date of Illness Onset
Primary occupation
Military Service
Military Service Year
Tetanus Toxoid Vaccination

Year of last tetanus dose
Acute wound
Acute wound date
Acute wound anatomic site
Acute wound work related
Acute wound environment
Acute wound circumstances
Acute wound type
Wound Contaminated
Depth of Wound

Acute wound signs of infection
Denervated Tissue Present
Acute wound medical care
Acute wound tetanus toxiod
administered
If Yes, tetanus toxiod administered,
How Soon after Injury?
Wound Debrided
If Yes, Debrided How Soon after
Injury?
TIG given before symptom onset
If Yes, TIG Given How Soon after
Injury?
TIG given before symptom onset
dosage
Tetanus Associated Condition
Diabetes
Insulin dependents
Parenteral Drug Abuse?
Tetanus type

TIG given after symptom onset
If Yes, How Soon after Injury?
TIG given after symptom onset
dosage
Intensive Care Unit
Mechanical Ventilation Days
Final outcome
Mother's Age
Mother's DOB
Date mother first resided in the U.S.
Mother tetanus vacc number of
known doses
Last time mother received tetanus
vacc
Infant's birth place location
Birth attendees

Description
Date of the beginning of the illness. Reported date of the onset of symptoms of the
condition being reported to the public health system
Specifies patient's primary occupation.
History of Military (Active or Reserve)?
Year of Entry into Militart Service
Tetanus Toxoid (TT) History Prior to
Tetanus Disease
(Exclude Doses Received Since Acute Injury)

Specifies the year of patients' last tetanus dose.
Did the patient have an acute wound or injury?
This field indicates the date an acute wound or injury occurred.
Specifies the anatomic site of acute wound or injury.
If there was an acute wound or injury, was it work related?
Specifies the environment where the acute wound or injury was work related.
Specifies the circumstances under which the acute wound or injury occurred.
Specifies the principle acute wound or injury type.
Wound Contaminated
Depth of Wound

Were there signs of infection at the time of care for the acute wound or injury?
Devitalized, Ischemic, or Denervated Tissue Present?
Did the patient obtain medical care for the acute wound or injury before tetanus
symptom onset?
Was patient administered tetanus toxiod (Td, TT, DT, DTaP) for the acute wound or
injury before tetanus symptom onset?
If Yes, How Soon after Injury?
Wound Debrided before Tetanus Onset
If Yes, Debrided How Soon after Injury?
Indicates whether tetanus immune globulin (TIG) prophylaxis was given as a part of the
wound care before tetanus symptom onset.
If Yes, TIG Given How Soon after Injury?
Specifies the date the tetanus immune globulin (TIG) prophylaxis units given.
Tetanus Associated Conditions Prior to Onset(If no Acute Injury)
Indicates whether patient have diabetes.
Indicates whether the patient is insulin dependent.
Pranteral Drug Abuse?
Type of tetanus.

Indicates whether the tetanus immune globulin (TIG) therapy was given after symptom
onset.
If Yes, How Soon after Injury?
Specifies the total therapeutic TIG dosage.
Was the patient in the Intensive Care Unit (ICU)?
Number of days the patient received mechanically ventilation.
Final outcome (e.g. Recovered, Died, Unknown)
Specifies mothers age.
Specifies mothers DOB.
Date mother first resided in the U.S.
Specifies number of known tetanus vaccination doses mother received prior to the
infant's (case's) birth.
Specifies number of years or months since mother received last tetanus vaccination.
Specifies infant's (case) birth place location (e.g. Hospital, Home, Other, Unknown).
Specifies birth attendees (e.g. Physician, Nurse, Licensed midwife, Unlicensed midwife,
Family, EMS technician(s)).

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

PHVS_YesNoUnknown_CDC
0 = Never
1 = 1 dose
2 = 2 doses
3 = 3 doses
4 = 4 + doses
9 = Unknown
PHVS_YesNoUnknown_CDC
Body Region (Tetanus)
PHVS_YesNoUnknown_CDC
Injury Occurred Environment (VPD)
Injury Type (VPD)
PHVS_YesNoUnknown_CDC
1 = 1 cm or les
2 = more than 1 cm
9 = Unknown
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_AftterInjury_Time
PHVS_YesNoUnknown_CDC
PHVS_AftterInjury_Time
PHVS_YesNoUnknown_CDC
PHVS_AftterInjury_Time

PHVS_TET_Associated_Conditions
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
Tetanus Type (VPD)

PHVS_YesNoUnknown_CDC
PHVS_AftterInjury_Time

PHVS_YesNoUnknown_CDC
Treatment Outcome Tetanus (VPD)

PHVS_VaccineDosesReceived_Tetanus

PHVS_BirthLocation_VPD
PHVS_BirthAttendees_VPD

Label/Short Name
Eosinophilia
Eosin Absolute
Eosin Units
Fever
Temperature
Temperature Units
Trichinellosis Signs and Symptoms
Code(s)
Trichinellosis Signs and Symptoms
Other
Suspected Foods
Pork Type Code
Pork Type Other
Pork Consumed Date
Pork Larvae Found
Pork Source Obtained Code
Pork Source Other
Pork Prep Code
Pork Prep Other
Pork Cook Method Code
Pork Cook Method Other
Non-Pork Type Code
Non-Pork Type Other
Non-Pork Consumed Date
Non-Pork Larvae Found Code
Non-Pork Source Code
Non-Pork Source Other
Non-Pork Prep Code
Non-Pork Prep Other
Non-Pork Method Code
Non-Pork Method Other
Reporting Lab Name
Reporting Lab CLIA Number
Local record ID (case ID)

Filler Order Number
Ordered Test Name

Date of Specimen Collection

Specimen Site
Specimen Number
Specimen Source
Specimen Details
Date Sample Received at Lab
Sample Analyzed date
Lab Report Date
Report Status
Resulted Test Name
Numeric Result
Result Units
Coded Result Value
Organism Name
Lab Result Text Value
Result Status
Interpretation Flag

Reference Range From
Reference Range To
Test Method
Lab Result Comments

Date received in state public health
lab
Lab Test Coded Comments
Sent to CDC for Genotyping
Genotyping Sent Date
Sent For Strain ID
Strain Type
Track Isolate
Patient status at specimen collection
Isolate received in state public health
lab
Reason isolate not received
Reason isolate not received (Other)
Date received in state public health
lab

State public health lab isolate id
number
Case confirmed at state public health
lab

Description
Did patient have Eosinophilia?
If "Yes," please specify absolute number or percentage:
Specify percent or numeric
Did patient have a fever?
If "Yes," please specify temperature:
Specify fahrenheit or celsius
Did patient have any of the following signs or symptoms of Trichinellosis?
If "Other," please specify other signs or symptoms of Trichinellosis:
What suspect foods did the patient eat?
Please specify type of pork:
If “Other,” please specify other type of pork:
Date suspect food was consumed:
Was larvae found in suspect food?
Where was the suspect meat obtained?
If “Other,” please specify where suspect meat was obtained:
How was suspect food prepared or further processed after purchase?
If “Other,” please specify other type of processing:
What was the method of cooking the suspect food?
If “Other,” please specify other type of cooking method:
Please specify type of non-pork:
If “Other,” please specify other type of non-pork:
Date suspect food was consumed:
Was larvae found in suspect food?
Where was the suspect meat obtained?
If “Other,” please specify where suspect meat was obtained:
How was suspect food prepared or further processed after purchase?
If “Other,” please specify other type of processing:
What was the method of cooking the suspect food?
If “Other,” please specify other type of cooking method:
Name of Laboratory that reported test result.
CLIA (Clinical Laboratory Improvement Act) identifier for the laboratory that performed
the test.
Sending system-assigned local ID of the case investigation with which the subject is
associated. This field has been added to provide the mapping to the case/investigation
to which this lab result is associated. This field should appear exactly as it appears in
OBR-3 of the Case Notification.
A laboratory generated number that identifies the test/order instance.
Ordered Test Name is the lab test ordered by the physician. It will always be included
in an ELR, but there are many instances in which the user entering manual reports will
not have access to this information.
The date the specimen was collected.

This indicates the physical location, of the subject, where the specimen originated.
Examples include: Right Internal Jugular, Left Arm, Buttock, Right Eye, etc.
A laboratory generated number that identifies the specimen related to this test.
The medium from which the specimen originated. Examples include whole blood,
saliva, urine, etc.
Specimen details if specimen information entered as text.
Date Sample Received at Lab (accession date).
The date and time the sample was analyzed by the laboratory.
Date result sent from Reporting Laboratory.
The status of the lab report.
The lab test that was run on the specimen.
Results expressed as numeric value/quantitative result.
The unit of measure for numeric result value.
Coded qualitative result value (e.g., Positive, Negative).
The organism name as a test result. This element is used when the result was reported
as an organism.
Textual result value, used if result is neither numeric nor coded.
The Result Status is the degree of completion of the lab test.
The interpretation flag identifies a result that is not typical as well as how it's not
typical. Examples: Susceptible, Resistant, Normal, Above upper panic limits, below
absolute low.
The reference range from value allows the user to enter the value on one end of a
expected range of results for the test. This is used mostly for quantitative results.
The reference range to value allows the user to enter the value on the other end of a
valid range of results for the test. This is used mostly for quantitative results.
The technique or method used to perform the test and obtain the test results.
Examples: Serum Neutralization, Titration, dipstick, test strip, anaerobic culture.
Comments having to do specifically with the lab result test. These are the comments
from the NTE segment if the result was originally an Electronic Laboratory Report.
Date the isolate was received in state public health laboratory.
Explanation for missing result (e.g., clotting, quantity not sufficient, etc.)
Indicate whether the specimens were sent to CDC for genotyping.
If the specimen was sent to the CDC for genotyping, date on which the specimens were
sent.
Indicate whether the specimen was sent for strain identification.
If the specimen was sent for strain identification, indicate the strain.
Track Isolate functionality indicator
Patient status at specimen collection
Isolate received in state public health lab
Reason isolate not received
Reason isolate not received (Other)
Date received in state public health lab

State public health lab isolate id number
Case confirmed at state public health lab

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
PHVS_YesNoUnknown_CDC
Eosin Units_FDD
PHVS_YesNoUnknown_CDC
PHVS_TemperatureUnit_UCUM
PHVS_TrichinellosisSignsSymptoms _FDD

PHVS_SuspectedFoodConsumed_FDD
PHVS_PorkType_FDD

PHVS_PresentAbsentUnkNotExamined_CDC
PHVS_MeatPurchaseInfo_FDD
PHVS_FoodProcessingMethod_FDD
PHVS_FoodCookingMethod_FDD
PHVS_NonPorkType_FDD

PHVS_PresentAbsentUnkNotExamined_CDC
PHVS_MeatPurchaseInfo_FDD
PHVS_FoodProcessingMethod_FDD
PHVS_FoodCookingMethod_FDD

PHVS_BodySite_CDC

PHVS_Specimen_CDC

PHVS_ResultStatus_HL7_2x
PHVS_LabTestName_CDC
PHVS_UnitsOfMeasure_CDC
PHVS_LabTestResultQualitative_CDC
PHVS_Microorganism_CDC

PHVS_ObservationResultStatus_HL7_2x
PHVS_AbnormalFlag_HL7_2x

PHVS_LabTestMethods_CDC

PHVS_MissingLabResult_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_MicrobiologicalStrain_CDC
PHVS_TrueFalse_CDC
PHVS_PatientLocationStatusAtSpecimenCollection
PHVS_YesNoUnknown_CDC
PHVS_IsolateNotReceivedReason_NND

PHVS_YesNoUnknown_CDC

Label/Short Name
Formtype
CDCNUM
StateEpiNumber
SLABSID
SLABSID2
SpecNumber
SpecNumber2
SpecNumber3
Year
Date Entered
Date Rec CDC
State
Name
DOB
Age
Sex
Foodhand
Citizen
Othcitzn
Ill
Dtonset
Hosp
Hospdays
Outcome
Dtisol
Site
Othsite
Serotype
Sensi
Ampr
Chlorr
Tmpsmxr
quinol
Ceft
outbreak
vac5yr
stanvax

yrstanvx
ty21vax
yrty21
vicps
yrvicps
outus
country1
country2
country3
country4
country1oth
country2oth
country3oth
country4oth
dtentus
business
tourism
visitfam
immigrat
othtrav
travreas
anycarr
prevcarr
comment
dtform

Description
Type of form reported on (9=carrier form or known carrier)
CDC Number
State Epi Number
State Lab Isolate ID Number
State Lab Isolate ID Number 2, maybe if another entry is associated in NARMS data
NARMS Isolate Identification Number
NARMS Isolate Identification Number- for dulplicate sample from a single patient
NARMS Isolate Identification Number- for dulplicate sample from a single patient
Year of report (based on date onset)
Date Form was entered into database
Date Form was received to CDC
Reporting State
First three letters of patient's last name
Date of Birth
Age
Sex (1=Male 2=Female)
Work as foodhandler? (1=Yes, 2=No, 9=unknown 3=didn't answer)
Citizen (1=US 2=other 9=unknown 3=didn't answer) CSP CHANGED CODE (before,
3=unknown, 9=didn't answer) WAIT to change in SAS
Other citizenship
Ill with typhoid fever (1=Yes 2=No 9=Unknown 3=didn't answer) CSP CHANGED CODE
(before, 3=unknown, 9 didn't answer) Changed in SAS!
Date of onset of Symptoms
Hospitalized? (1=Yes 2=No, 9=unknown, 3=didn't answer)
Days hospitalized
NOTE -- 999= didn't answer in a field like this!
Outcome of case (1=Recovered 2=Died 3=didn't answer 9=unknown)
Date Salmonella first isolated
Sites of isolation (1=Blood 2=Stool 3=didn't answer 9=unknown 4=gallbalder 5=other)
CAREFUL with this variable - LOTS of dif. codes!
Other site of isolation
Was sensitivity testing done? (1=Yes 2=No 9=unknown 3=didn't answer)
Resistant to ampicillin on form 3? (1=Yes 2=No 7=not tested 3=didn't answer
9=unknown)
Resistant to chloramphenicol on form 3? (1=Yes 2=No 7=not tested 3=didn't answer
9=unknown)
Resistant to trimethoprim-sulfamethoxazole on form 3? (1=Yes 2=No 7=not tested
3=didn't answer 9=unknown)
Resistant to fluoroquinolone on form 3? (1=Yes 2=No 7=not tested 3=didn't answer
9=unknown)
Reistant to ceftriaxone (1=Yes 2=No 9=unknown)
Case occur as part of outbreak? (1=Yes 2=No 9=unknown 3=didn't answer)
Vaccinated within 5 yrs? (1=Yes 2=No 9=unknown 3=didn't answer)
Standard Killed typhoid shot (1=Yes 2=No, 9=unknown, 3=didn't answer)

Year standard vaccine received
Oral Ty 21a or Vivotof four pill series (1=Yes 2=No, 9=unknown, 3=didn't answer)
Year of Oral Ty 21a or Vivotof four pill series received
VICPS or Typhium VI shot (1=Yes 2=No, 9=unknown, 3=didn't answer)
Year VICPS or Typhium VI shot received
Travel outsiide of US? (1=Yes 2=No 9=unknown 3=didn't answer)
Country 1 visited
Country 2 visited
Country 3 visited
Country 4 visited
country 1 other
country 2 other
country 3 other
country 4 other
Date of most return or entry in the US
Business is purpose of international travel(1=Yes 2=No 9=unknown 3=didn't answer)
Tourism is purpose of international travel(1=Yes 2=No 9=unknown 3=didn't answer)
Visting relatives or friends is purpose of international travel(1=Yes 2=No 9=unknown
3=didn't answer)
Immigration to the US is purpose of international travel (1=Yes 2=No 9=unknown
3=didn't answer)
Other travel is purpose of international travel(1=Yes 2=No 9=unknown 3=didn't
answer)Reason for other travel
Reason for other travel
Case traced to typhoid carrier? (1=Yes 2=No 9=unknown 3=didn't answer)
Carrier previously known to health dept (1=Yes 2=No 9=unknown 3=didn't answer)
Comments
Date PH Dept completed form

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)

Label/Short Name
Number of lesions in total
Number of lesions if less than 50
Did the patient receive Varicellacontaining vaccine
Reason why patient did not receive
Varicella-containing vaccine
Other reason why patient did not
receive Varicella-containing vaccine

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
Choose the numeric range within which a count of the patient's lesions falls. Note that PHVS_NumberOfLesions_VZ
if "Unknown" is sent, the HL7 Flavor of Null UNK value is sent.
Number of lesions if less than 50
Indicate whether the patient received varicella-containing vaccine; a value of Yes or No PHVS_YesNoUnknown_CDC
enables other fields in this section, allowing for answers to their questions.
If the value in Did the patient receive varicella-containing vaccine? is No, choose the
PHVS_VaccineNotGivenReasons_CDC
reason why the patient did not receive the vaccine; if none of the specific choices in
the list apply, choose Other.
If the value specified in Reason why patient did not receive varicella-containing vaccine
is Other, indicate the reason (a reason other than those provided in the list).
Description

Number of doses received on or after If the value in Did the patient receive varicella-containing vaccine? is Yes, indicate the
first birthday
number of doses received on or after the patient's first birthday.
PHVS_VaccineNotGivenReasons_CDC
Reason patient is >= 6 years old and Reason patient is >= 6 years old and received one dose on or after 6th birthday but
received one dose on or after 6th
never received second dose. Choose from the list the reason the patient never
birthday but never received second received the second dose; if none of the specific choices in the list apply, choose
dose
Other.”
Other reason patient did not receive If the value specified in Reason patient is >= 6 years old and received one dose on or
second dose
after 6th birthday but never received second dose is Other, indicate the reason (a
reason other than those provided in the list).
Rash Onset Date
Date on which the physical manifestations of the illness—the rash—appeared
Rash Location
The distribution of the rash on the body
PHVS_RashDistribution_VZ
Dermatome
If a value of Focal is specified in the Rash Location field, enter the nerve where the rash
occurred (lumbar or thoracic, with a number)
If a value of Generalized is specified for the Rash Location field, choose location where PHVS_RashLocationFirstNoted_VZ
Location First Noted
rash was first noted (if any); if none of the specific choices in the list apply, choose
Other.
If a value of Other is specified in the Location First Noted, enter the location (i.e., the
Other Generalized rash location
location where the rash was first noted is other than one of the values provided in the
Location First Noted list)
If the value specified in Total Number of Lesions is < 50, indicate whether macules
Macules Present
PHVS_YesNoUnknown_CDC
were present.
If the value specified in Macules Present is Yes, indicate how many macules were
Number of Macules
present.
Papules Present
If the value specified in Total Number of Lesions is < 50, indicate whether papules were PHVS_YesNoUnknown_CDC
present.
If the value specified in Papules Present is Yes, indicate how many papules were
Number of Papules
present.
Vesicles Present
If the value specified in Total Number of Lesions is < 50, indicate whether vesicles were PHVS_YesNoUnknown_CDC
present.
If the value specified in Vesicles Present is Yes, indicate how many vesicles were
Number of Vesicles
present.
Mostly macular/papular
Indicate whether the lesions were mostly macular/papular.
PHVS_YesNoUnknown_CDC
Mostly vesicular
Indicate whether the lesions were mostly vesicular.
PHVS_YesNoUnknown_CDC
Hemorrhagic
Indicate whether the rash was hemorrhagic.
PHVS_YesNoUnknown_CDC
Itchy
Indicate whether the patient complained of itchiness.
PHVS_YesNoUnknown_CDC
Scabs
Indicate whether there were scabs.
PHVS_YesNoUnknown_CDC
Crops/Waves
Indicate whether the lesions appeared in crops or waves.
PHVS_YesNoUnknown_CDC
Did rash crust
Indicate whether the rash crusted.
PHVS_YesNoUnknown_CDC
Number of Days until lesions crusted If the value specified in Did the rash crust? is Yes, enter the number of days that
over
transpired for all of the lesions to crust over.
Number of Days rash lasted
If the value specified in Did the rash crust? is No, enter the number of days that the
rash was present.
Fever
Indicate whether the patient had a fever during the course of the illness.
PHVS_YesNoUnknown_CDC
If the value specified in Did patient have fever? is Yes, indicate the date when the fever
Fever Onset Date
began.
Highest measured temperature
If the value specified in Did patient have fever? is Yes, indicate the highest temperature
that was measured.
Temperature Units
Temperature Units (Fahrenheit or Celsius).
PHVS_TemperatureUnit_UCUM
Fever Duration in Days
If the value specified in Did patient have fever? is Yes, indicate the number of days for
which the patient had a fever.
Is patient immunocompromised due Indicate whether the patient was immunocompromised (anergic).
PHVS_YesNoUnknown_CDC
to medical condition or treatment
Medical Condition or Treatment
Did patient visit a healthcare
provider during this illness
Did patient develop any
complications that were diagnosed
by a healthcare provider?
Skin/soft tissue infection

If Yes, indicate the medical condition or treatment associated with the patient being
immunocompromised
PHVS_YesNoUnknown_CDC
Indicate whether the patient visited a healthcare provider during the course of this
illness.
If the value specified in Did patient visit a healthcare provider during this illness? is Yes, PHVS_YesNoUnknown_CDC
indicate whether the patient developed complications (as described).
If the value specified in Did patient develop any complications that were diagnosed by PHVS_YesNoUnknown_CDC
a healthcare provider? is Yes, indicate whether there was skin or soft tissue infection.

Cerebellitis/ ataxia

If the value specified in Did patient develop any complications that were diagnosed by PHVS_YesNoUnknown_CDC
a healthcare provider? is Yes, indicate whether there was cerebellitis/ataxia.

Encephalitis

If the value specified in Did patient develop any complications that were diagnosed by PHVS_YesNoUnknown_CDC
a healthcare provider? is Yes, indicate whether there was encephalitis.

Dehydration

If the value specified in Did patient develop any complications that were diagnosed by PHVS_YesNoUnknown_CDC
a healthcare provider? is Yes, indicate whether the patient was diagnosed as being
dehydrated.
If the value specified in Did patient develop any complications that were diagnosed by PHVS_YesNoUnknown_CDC
a healthcare provider? is Yes, indicate whether there was hemorrhagic condition.

Hemorrhagic condition

Pneumonia

If the value specified in Did patient develop any complications that were diagnosed by PHVS_YesNoUnknown_CDC
a healthcare provider? is Yes, indicate whether pneumonia was a complication.

How was pneumonia diagnosed
Other complications

If the value in Pneumonia? is Yes, indicate how the pneumonia was diagnosed.
If the value specified in Did patient develop any complications that were diagnosed by
a healthcare provider? is Yes, indicate whether there were other complications not
cited here.
If the value specified in Other Complications? Is Yes, list the other complication(s)
Indicate whether the patient was treated with acyclovir, famvir, or any licensed
antiviral.
If the value specified in Antiviral? is yes, list the name of the medication.
If Name of Medication is ‘other’, indicate name of medication
Start date of medication.
Stop date of medication.
If a value of Yes is specified in Did the patient die from this illness or complications
associated with this illness?, indicate whether an autopsy was performed for the
death.
If a value of Yes is specified in Did the patient die from this illness or complications
associated with this illness?, indicate the official cause of death.
Indicate whether the patient has a prior diagnosis of varicella.
Age at diagnosis

Other complication details
Antiviral treatment
Name of medication
Name of the Medication if ‘Other’
Start Date of Medication
Stop Date of medication
Autopsy performed

Cause of death
Diagnosed with Varicella before
Age at diagnosis

PHVS_DiagnosedPneumoniaBy_VZ
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_MedicationReceived _VZ

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC

Age at diagnosis units
Previous Case Diagnosed by
Previous Case Diagnosed by Other

Age at diagnosis units
Indicate who diagnosed the illness; if none of the choices apply choose Other.
If the value specified in Previous Case Diagnosed by is Other, indicate who diagnosed
the case
Indicate whether this case is epi-linked to another case (confirmed or probable).

PHVS_AgeUnit_UCUM
PHVS_Diagnosed_By_VZ

Is this case epi-linked to another
PHVS_YesNoUnknown_CDC
confirmed or probable case
Type of case this case is epi-linked to If the value specified in Is this case epi-linked to another confirmed or probable case? is PHVS_EpilinkedCaseType_VZ
Yes, indicate the kind of case with which the current case is epi-linked.
Transmission setting (setting of
Location where the patient was exposed to the illness; if none of the specific choices in PHVS_TransmissionSetting_NND
exposure)
the list apply, choose Other.
Other transmission setting
If the value specified in Transmission Setting? is Other, describe the other transmission
setting.
Is this case a healthcare worker
Indicate whether the patient who is the subject of the current case is a healthcare
PHVS_YesNoUnknown_CDC
worker.
If the patient was pregnant during the illness, indicate the number of weeks of
Number of weeks gestation
gestation at the onset of the illness.
Trimester
If the patient was pregnant during the illness, indicate the trimester at the onset of the PHVS_PregnancyTrimester_CDC
illness.
Was laboratory testing done for
Was laboratory testing done for varicella?
PHVS_YesNoUnknown_CDC
varicella?
Direct fluorescent antibody (DFA)? Was direct fluorescent antibody (DFA) testing performed?
PHVS_YesNoUnknown_CDC
Date of DFA
Date of DFA
DFA Result
DFA Result
PHVS_LabTestInterpretation_CDC
PCR specimen?
PCR specimen?
PHVS_YesNoUnknown_CDC
Date of PCR specimen
Date of PCR specimen
Source of PCR specimen
Source of PCR specimen
PHVS_PCRSpecimenSource_VZ
Specify other PCR source
Specify other PCR source
PCR Result
PCR Result
PHVS_LabTestInterpretation_CDC
Specify other PCR result
Specify other PCR result
Culture performed?
Culture performed?
PHVS_YesNoUnknown_CDC
Date of Culture Specimen
Date of Culture Specimen
Culture Result
Culture Result
PHVS_LabTestInterpretation_CDC
Was other laboratory testing done? Was other laboratory testing done?
PHVS_YesNoUnknown_CDC
Specify Other Test
Specify Other Test
PHVS_LabTestMethod_VZ
Date of Other test
Date of Other test
Other Lab Test Result
Other Lab Test Result
PHVS_LabTestInterpretation_CDC
Other Test Result Value
Other Test Result Value
Serology performed?
Serology performed?
PHVS_YesNoUnknown_CDC
IgM performed?
IgM performed?
PHVS_YesNoUnknown_CDC
Type of IgM Test
Type of IgM Test
PHVS_IgMTestType_VZ
Specify Other IgM Test
Specify Other IgM Test
Date IgM Specimen Taken
Date IgM Specimen Taken
IgM Test Result
IgM Test Result
PHVS_LabTestInterpretation_CDC
IgM Test Result Value
IgM Test Result Value
IgG performed?
IgG performed?
PHVS_YesNoUnknown_CDC
Type of IgG Test
Type of IgG Test
PHVS_IgGTestType_VZ
If "Whole Cell ELISA," specify
If "Whole Cell ELISA," specify manufacturer
PHVS_WholeCellELISAManufacturer_VZ
manufacturer
If "gp ELISA" specify manufacturer
If "gp ELISA" specify manufacturer
PHVS_gpELISAManufacturer_VZ
Specify Other IgG Test
Specify Other IgG Test
Date of IgG - Acute
Date of IgG - Acute
IgG - Acute Result
IgG - Acute Result
PHVS_LabTestInterpretation_CDC
IgG - Acute Test Result Value
IgG - Acute Test Result Value
Date of IgG - Convalescent
Date of IgG - Convalescent
IgG - Convalescent Result
IgG - Convalescent Result
PHVS_LabTestInterpretation_CDC
IgG - Convalescent Test Result Value IgG - Convalescent Test Result Value
Were the specimens sent to the CDC Were the specimens sent to the CDC for genotyping (molecular typing)?
for genotyping (molecular typing)?
Date sent for genotyping
Date sent for genotyping
Was specimen sent for strain (wild- Was specimen sent for strain (wild- or vaccine-type) identification?
or vaccine-type) identification?
Strain Type
Strain Type
Vaccine Administered
The type of vaccine administered.
Vaccine Manufacturer
Manufacturer of the vaccine.
Vaccine Lot Number
The vaccine lot number of the vaccine administered.
Vaccine Administered Date
The date that the vaccine was administered.
Case Investigation Status Code
Case Investigation Status Code, from NBS MM
Was subject vaccinated as recommended by ACIP?
Vaccinated per ACIP
recommendations
Reason not vaccinated per ACIP
Reason subject not vaccinated as recommended by ACIP
recommendations
If other, specify reason not vaccinated per ACIP
Reason not vaccinated per ACIP,
Other
Treatment duration
Number of days antiviral taken
Specimen Description
Text description of the specimen
Test Type, other
If other, specify lab test
Specimen sent to CDC
Was a specimen sent to CDC for testing?
Type of testing at CDC
What type of testing was done at CDC for this subject?
Type of testing at CDC, other
If other, specify testing done at CDC
Date specimen sent to CDC
Date specimen sent to CDC
Patient Address City
Patient address city, from NBS MM
Vaccine Administered Product Type, If other, specify type of vaccine administered
Other
Vaccine Product Manufacturer, Other If other, specify vaccine manufacturer
Date of last dose prior to illness
onset
Vaccination doses prior to onset
Vaccination Record ID
Vaccine Expiration Date
NDC Brand Name/Bar Code
information
Vaccine dose number
Vaccine Event information source
Immunization Schedule used
Exemption/refusal reason
Laboratory Confirmed
Performing Laboratory Type
Performing Laboratory Type, Other
VPD Lab Message Patient Identifier

Date of last disease-containing vaccination dose prior to illness onset
Number of disease-containing vaccination doses prior to illness onset
Vaccination Record ID, from NBS MM
Vaccine expiration date
NDC from the vaccine's bar code. With the NDC code, vaccine brand name and
manufacturer can be obtained.
Indicates the dose number in a series
Indicates whether the vaccine was administered by the provider organization recording
the immunization or obtained from a historical record
Identifies the schedule used for immunization evaluation and forecast.
Indicates the reason the patient is either exempt from the immunization or refuses the
immunization
Was the case laboratory confirmed?
Performing laboratory type
If other, specify performing laboratory type
VPD Lab Message Patient Identifier

PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_StrainType_VZ
PHVS_VaccinesAdministeredCVX_CDC_NIP
PHVS_ManufacturersOfVaccinesMVX_CDC_NIP

VPD Lab Message Observation
VPD Lab Message Observation Identifier
Identifier
VPD Lab Message Observation Value VPD Lab Message Observation Value
Specimen Collection Date
Specimen Source
Numeric Test Result
Numeric Test Result Units
Chest X-ray result
Was the rash generalized
Reason for Hospitalization

Date of specimen collection
The medium from which the specimen originated
Numeric quantitative result of the test(s) performed for this case
Numeric quantitative result unit of the test(s) performed for this case
Chest X-ray result
Was the rash generalized
If the subject was hospitalized because of this event, indicate the reason(s).

Label/Short Name
AGEMM
AGEYY
CDCNUM
CITY
COUNTY
DATECOMP
DOB
ETHNICITY
FDANUM
FNAME
LNAME
OCCUPAT
RACE
SEX
STATE
STEPINUM
STLABNUM
FEVER
NAUSEA
VOMIT
DIARRHEA
VISBLOOD
CRAMPS
HEADACHE
MUSCPAIN
CELLULIT
BULLAE
SHOCK
OTHER
MAXTEMP
CENFAR
NUMSTLS
CELLSITE
BULLSITE
OTHSPEC2
AMPMSYMP
ANTIBYN
Descant1
Descant2
Descant3
ANTNAM01
ANTNAM02
ANTNAM03

ANTNAM04
BEGANT1
BEGANT2
BEGANT3
BEGANT4
CDCISOL
DATEADMN
DATEDIED
DATEDISC
DATESYMP
DURILL
ENDANT1
ENDANT2
ENDANT3
ENDANT4
GSURGTYP
HEMOTYPE
HHSYMP
HOSPYN
IMMTYPE
LIVTYPE
MALTYPE
MISYMP
OTHCONSP
PATDIE
PEPULCER
ALCOHOL
DIABETES
INSULIN
GASSURG
HEART
HEARTFAL
HEMOTOL
IMMUNOD
LIVER
MALIGN
RENAL
RENTYPE
OTHCOND
TRTANTI
TRTCHEM
TRTRADIO
TRTSTER
TRTIMMUN
TRTACID

TRTULCER
SEQDESC
SEQUELAE
TRTACISP
TRTANTSP
TRTCHESP
TRTIMMSP
TRTRADSP
TRTSTESP
TRTULCSP
DATESPEC
SPECIESNAME
SITE
STATECON
SOURCE
OTHORGAN
SPECORGAN
AMBTEMFC
AMNTCONS
AMPMCONS
DATEAMBT
DATEFECL
DATEH2O
DATEHAR1
DATEHAR2
DATERAIN
DATESALN
DATESEAR
FECALCNT
H2OSALIN
HARVSIT1
HARVSIT2
HARVST01
HARVST02
HARVSTS1
HARVSTS2
HHCONSUM
IMPROPER
MAMTEMP
MICONSUM
RAINFALL
RESTINV
SEADISSP
SEADIST
SEAHARV

SEAIMPOR
SEAIMPSP
SEAOBT
SEAOBTSP
SEAPREP
SEAPRSP
SH2OTEMP
SH2OTMFC
SOURCES
SHIPPERS
TAGSAVA
TYPESEAF
HARVESTSTATE
HARVESTREGION
TRVROTHR
AMPMEXP
HANDLING
SWIMMING
WALKING
BOATING
CONSTRN
BITTEN
ANYWLIFE
BODYH2O
CONSTRN
DATEEXPO
DATEWHI1
DATEWHI2
DATEWHI3
DATEWHO1
DATEWHO2
DATEWHO3
FISHSP
H2OCOMM
H2OTYPE
HHEXPOS
LOCEXPOS
MIEXPOS
OTHEREXP
OTHERH2O
OTHSHSP
OUTBREAK
OUTBRKSP
CLAMS
CRAB

LOBSTER
MUSS
OYSTER
SHRIMP
CRAY
OTHSH
FISH
RCLAM
RCRAB
RLOBSTER
RMUSS
ROYSTER
RSHRIMP
RCRAY
ROTHSH
RFISH
DATECLAM
DATECRAB
DATELOBS
DATEMUSS
DATEOYSTER
DATESHRI
DATECRAY
DATEOTHSH
DATEFISH
SPECEXPO
STRESID
TRAVEL
WHERE01
WHERE02
WHERE03
WOUNDEXP
WOUNDSP

Description
Age in months
Age in years
CDC Number
City
County
Date completing form
Date of birth
Hispanic or Latino origin?
FDA Number
First 3 letters of first name
First 3 letters of last name
Occupation
Race
Sex
State of exposure (usually reporting state)
State Number
State Lab Number
Fever
Nausea
Vomiting
Diarrhea
Bloody stool
Abdominal cramps
Headache
Muscle Pain
Cellulitis
Bullae
Shock
Other
Symptom: Maximum temp of fever
Fever measured in units of C or F
Symptom: # of stools/24 hours
Symptom: Site of cellulitis
Symtom: Site of Bullae
Symptom: Specify other Symptoms
Seafood Investigation: Onset in am or pm
Did patient receive antibiotics?
Name of 1st Antibiotic
Name of 2nd Antibiotic
Name of 3rd Antibiotic
Name of 1st Antibiotic (old)
Name of 2nd Antibiotic (old)
Name of 3rd Antibiotic (old)

Name of 4th Antibiotic (old)
Date began Antibiotic #1
Date began Antibiotic #2
Date began Antibiotic #3
Date began Antibiotic #4
CDC Isolate No.
Date admitted to hospital
Date of death
Date of discharge from hospital
Date of symptom onset
# days ill
Date ended Antibiotic #1
Date ended Antibiotic #2
Date ended Antibiotic #3
Date ended Antibiotic #4
Pre-existing: Type of gastric surgery
Pre-exisiting: Type of hemotological disease
Hour of symptom onset
Hospitalized?
Pre-exisiting: Type of Immunodeficiency
Pre-exisiting: type of liver disease
Pre-existing: Type of Malignancy
Minute of symptom exposure
Pre-existing: Type of Other condition
Did patient die?
Pre-existing: Peptic ulcer
Pre-existing: Alcoholism
Pre-existing: Diabetes
Pre-existing: on insulin?
Pre-existing: Gastric surgery
Pre-existing: Heart disease
Pre-existing: Heart failure?
Pre-existing: Hematologic disease
Pre-existing: Immunodeficiency
Pre-existing: Liver disease
Pre-existing: Malignancy
Pre-existing: Renal disease
Pre-existing: Type of renal disease
Pre-existing: Other
Type of treatment received: antibiotics
Type of treatment received: chemotherapy
Type of treatment received: radiotherapy
Type of treatment received: systemic steroids
Type of treatment received: immunosuppressants
Type of treatment received: antacids

Type of treatment received: H2 Blocker or other ulcer medication
Describe Sequelae
Sequelae?
If previously treated with Antacids, specifiy
If previously treated with Antibiotics, specifiy
If previously treated with chemotherapy, specifiy
If previously treated with immunosuppressants, specifiy
If previously treated with radiotherapy, specifiy
If previously treated with steroids, specifiy
If treated with ulcer meds, specifiy
Date specimen collected
Species
If other source, specify site from which Vibrio was isolated
Was Species confirmed at State PH Lab?
Specimen source
Other organism isolated from specimen?
Specify other organism isolated
Seafood Investigation: Maximum ambient temp units - F or C
Seafood Investigation: Amount of shellfish consumed
Seafood Investigation: Shellfish consumed in am or pm
Seafood investigation: Date ambient temp measured
Seafood Investigation: Date of fecal count
Seafood Investigation: Date water temp measured
Seafood Investigation: Date of harvest #1
Seafood Investigation: Date of harvest #2
Seafood Investigation: Date total rain fall recorded
Seafood Investigation: Date salinity measured
Seafood Investigation: Date restaurant rec'd seafood
Seafood Investigation: Fecal Coliform Count
Seafood Investigation: Results of Salinity test
Seafood Investigation: Harvest Site #1
Seafood Investigation: Harvest Site #2
Seafood Investigation: Status of Harvest Site #1
Seafood Investigation: Status of Harvest Site #2
Seafood Investigation: Specify if Status for Harvest Site #1 = other
Seafood Investigation: Specify if Status for Harvest Site #2 = other
Seafood Investigation: Hour of seafood consumption
Seafood Investigtaion: Improper Storage?
Seafood Investigation: Maximum ambient temp
Seafood Investigation: Minute of seafood consumption
Seafood Investigation: Total rainfall in Inches
Seafood Investigation: Investigation of Restaurant?
Seafood Investigation: Specify how shellfish distributed
Seafood Investigation: How is shellfish distributed?
Seafood Investigation: Was shellfish harvested by patient or friend?

Seafood Investigation: Was seafood imported?
Seafood Investigation: Specify country of Import
Seafood Investigation: where was seafood obtained?
Seafood Investigation: Specify from where seafood was obtained
Seafood Investigation: How was seafood prepared?
Seafood Investigation: Specify how seafood was prepared (if other)
Seafood Investigation: Surface water temperature
Surface water temp units in F or C?
Sources of seafood
Shippers who handled suspected seafood (certification numbers)
Seafood investigation: Are tags available from suspect lot?
Seafood investigation: Type of shellfish consumed
State in which seafood was harvested
Region in which seafood was harvested
Cholera, reason for travel: specify if other
Seafood Investigation: Exposure to seawater in am or pm
Exposure: handing/cleaning seafood
Exposure: Swimming/diving/wading
Exposure: Walking on beach/shore/fell on rocks/shells
Exposure: Boating/skiing/surfing
Exposure: Construction/repairs
Exposure: Bitten/stung
Exposure: Contact with other marine/freshwater life
Exposure: Exposure to a body of water
Exposure to water via construction
Exposure: Date of exposure to seawater
Date traveled/entered destination #1
Date traveled/entered destination #2
Date traveled/entered destination #3
Date left/returned home #1
Date left/returned home #2
Date left/returned home #3
Type of fish
Exposure: Comments on water exposure
Exposure: Type of water exposure
Exposure: Hour of seawater exposure
Exposure: location of water exposure
Exposure: Minute of seawater exposure
Exposure: Other exposure
Exposure: Exposed to other water not listed?
Specify other shellfish consumed
Is case part of outbreak?
If part of an outbreak, Specify outbreak
Consumption: clams
Consumption: crab

Consumption: lobster
Consumption: mussels
Consumption: oysters
Consumption: shrimp
Consumption: crawfish
Consumption: other shellfish
Consumption: other fish
Raw consumption: clams
Raw consumption: crab
Raw consumption: lobster
Raw consumption: muss
Raw consumption: oyster
Raw consumption: shrimp
Raw consumption: crawfish
Raw consumption: other shellfish
Raw consumption: other fish
Date of seafood consumption: clams
Date of seafood consumption: crab
Date of seafood consumption: lobster
Date of seafood consumption: mussels
Date of seafood consumption: oysters
Date of seafood consumption: shrimp
Date of seafood consumption: crawfish
Date of seafood consumption: other shellfish
Date of seafood consumption: other fish
Specify other seawater/shellfish dripping exposure (if other)
State of residence
Exposure to travel outside home state in previous 7 days?
Travel destination #1
Travel destination #2
Travel destination #3
Did patient incur a wound before/during exposure?
If patient incurred wound before/during exposure, describe wound

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)