Form 17AHK Att. 4 - ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs) INVAS

Patient’s Name

Patient’s Date of Birth

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– Patient identifier information is not transmitted to CDC –

2017 ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs) INVASIVE
PNEUMOCOCCAL DISEASE IN CHILDREN (aged ≥2 months to <5 years)
StateID:

Date of positive culture

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Date form completed

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Form Approved
OMB No. 0920-0978

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—VACCINE HISTORY—
Child has never received vaccines

VACCINES

Dose #

Dates of immunizations

Vaccination history unknown

Manufacturer

Vaccine name

Lot #

1

Pneumococcal
conjugate vaccine

2

Prevnar13® (PCV13)

3
4
5
6

Pneumococcal
polysaccharide vaccine

1

Pnuemovax®23 (PPSV23)

2
1

Data sources used for vaccination history:
2

Diphtheria/Tetanus/
Pertussis (DTP or DTaP)

Was health care provider information available from the
following sources?

3

Medical Chart:

Did Not Check

4
5

Vaccine Registry:

Did Not Check

Parent/Guardian:

Did Not Check

Refused

1

Haemophilus influenzae
type B (Hib)

If yes to any sources,
How many providers were contacted? ___

2
3

What sources were used for vaccination history?

4

Medical Chart:

Did Not Check

Vaccine Registry:

Did Not Check

Primary Care Provider:

Did Not Check

Other Provider:

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

Person completing the form (please print):
Name
Please return form to:

Title

Phone: (
Fax: (
Phone: (
Fax: (

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)
)
)

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless
it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden to CDC,
CDC/ATSDR Reports Clearance Oflcer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA(0920-0978). Do not send the completed form to this address.
CDC 52.15A REV. 10-2016