Att 10 - Disease-Specific Data_04302020_20200501

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Attachment 11: Disease-Specific Data
Subsequent tabs in this workbook describe the disease-specific data elements that are requested from each program area.

CDC Priority (Legacy):

Indicates whether the program specifies the field as:
R - Required - Mandatory for sending the message. If data element
is not present, the message will error out.
P - Preferred - This is an optional variable and there is no
requirement to send this information to CDC. However, if this
variable is already being collected by the state/territory, or if the
state/territory is planning to collect this information because it is
deemed important for your own programmatic needs, CDC would
like this information sent. CDC preferred variables are the most
important of the optional variables to be earmarked for CDC
analysis/assessment, even if sent from a small number of states.
O - Optional - This is an optional variable and there is no
requirement to send this information to CDC. This variable is
considered nice-to-know if the state/territory already collects this
information or is planning to collect this information, but has a lower
level of importance to CDC than the preferred classification of
optional data elements.

CDC Priority (New):

Indicates whether the program specifies the field as:
R - Required - This data element is mandatory for sending a
message. If the required data element is not present, the message
will be rejected. The required data elements alone are not sufficient
for national surveillance purposes
1-Priority 1 – Highest priority for reporting. These data elements are
critical for national surveillance activities. Jurisdiction’s data
collection system should be modified to collect Priority 1 data
elements. If this data element is not currently collected and
available to send, please discuss with the CDC Program whether you
can onboard without that element being available and included in
the messages. Some CDC programs may request a plan addressing
future inclusion of these data elements, if not able to collect and
transmit at onboarding.

Attachment 11: Disease-Specific Data
2 - Priority 2 – High priority data element that will support national
surveillance activities. If this data element is not currently collected
and available to send, please plan to update jurisdiction’s data
collection system. Some CDC programs may request a plan
addressing future inclusion of these data elements, if not able to
collect and transmit at onboarding.
3 - Priority 3 – Lower priority data element that should be
considered for inclusion in the surveillance system and case
notification. Please send if currently collected in the system.
10/27/2021

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
Medical Record ID
State Postal Code
Occupation State
Occupation County
Is the Subject a First Responder
What category of vaccine did the
subject get
Date last received
Booster Vaccine
Medication Received
Start Date of Treatment or Therapy
Date Treatment or Therapy Stopped
Signs and Symptoms
Signs and Symptoms Indicator
Diet
Smoking Status
Laboratory State
Laboratory City
CSID
Specimen Collected before
antibiotics
Transferred from Initial Hospital
Antimicrobials given for illness
Antimicrobial Name
Antimicrobial Start Date
Antimicrobial End Date
Number of Days of Treatment
Actual Route of Administration Attempted or Completed
Date AIG Given
Date Raxibacumab Given

On vasopressors for any length of
time
Route of Infection
International Destination(s) of
Recent Travel
Travel State
Public Transportation Route
Date Using Public Transportation
Exposure Source
Type of Animal Exposure
Animal Type
Lab Name
Contact Type
Location of Contact
Illicit Drug Specify
Location Name
Location Address
Attendance Date
Locations Routinely Visited
Time of Day
Date of last dose
Post-exposure or Treatment
Alcohol use frequency
Alcohol use quantity
Hospital Procedure
Diagnostic Test Findings
Treatment Type
Treatment Type Indicator

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"
TBD
TBD
TBD
TBD
Is the Subject a First Responder
What category of vaccine did the subject get
Date last received anthrax vaccine
If received a full series of pre-exposure vaccine, is the subject up-to-date on the annual
booster vaccine
If the case patient received post exposure antimicrobials, indicate the antimicrobials
received
What was the date that the case patient starting taking antimicrobials
What was the date that the case patient stopped taking antimicrobials
Signs and symptoms associated with Anthrax
Indicator for associated signs and symptoms
TBD
What is the patient's current tobacco smoking status?
State where laboratory is located
TBD
CDC specimen ID number from the 50.34 submission form. Example format (10-digit
number): 3000123456.
Was the specimen used for testing collected before antibiotics was taken?
Transferred from Initial Hospital
Antimicrobials given for illness
Antimicrobial Name
Antimicrobial Start Date
Antimicrobial End Date
Number of Days of Treatment
What is the route of antibiotic administration?
Date AIG Given
Date Raxibacumab Given

On vasopressors for any length of time
Suspected primary route of infection at time of evaluation (select all that apply):
List all international destinations (country) traveled during the 14 days prior to illness
onset
List all domestic destinations (state) traveled to during the 14 days prior to illness
onset
Specify public transportation route (e.g. name/number)
Specify date(s) using public transportation
Indicate the type of exposure the patient had in the 14 days prior to illness onset.
Types of exposure to animal.
If exposure type is Animal contact, specify animal the subject had contact with in the
14 days prior to illness onset. If the subject had contact with multiple animals
complete separate repeating groups for each one.
If worked in a clinical, microbiological, or animal research laboratory, specify lab.
If linked to confirmed case or contact with similar illness or sign and symptoms,
indicate type of contact.
If linked to confirmed case or contact with similar illness or sign and symptoms,
indicate geographic location where contact occurred (e.g. city, country, state).
If subject had contact with illicit drugs, specify the name or type of the drug.
Location name of place or event.
Location address of place or event (e.g. country, city, state, county.)
List all date(s) of event or place attendance.
Specify the name of a place that was routinely visited in the 14 days prior to illness
onset, such as a place of worship, volunteer, gym, etc.
List the time period during the day when the place was visited
Date last received anthrax vaccine
Indicates if medication received is for post-exposure or anthrax treatment.
In the past 30 days, how often does the patient take alcoholic drinks?
On the days when the case patient drank, about how many drinks did the case patient
drink on average?
If subject was hospitalized, were any of the following procedures or treatments done?
Results from procedures or treatments done in the hospital.
Listing of treatment or medical intervention the subject received for this illness.
Indicate if treatment was administered.

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

CDC Priority (Legacy)

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

N/A
N/A
TBD
TBD
PHVS_YesNoUnknown_CDC
TBD
N/A
PHVS_YesNoUnknown_CDC
TBD
N/A
N/A
TBD
PHVS_YesNoUnknown_CDC
TBD
TBD
PHVS_State_FIPS_5-2
N/A
N/A
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
TBD
N/A
N/A
N/A
TBD
N/A
N/A

PHVS_YesNoUnknown_CDC
TBD
PHVS_Country_ISO_3166-1
PHVS_State_FIPS_5-2
N/A
N/A
TBD
TBD
TBD
N/A
TBD
N/A
N/A
N/A
N/A
N/A
N/A
TBD
N/A
TBD
TBD
N/A
TBD
TBD
TBD
PHVS_YesNoUnknown_CDC

CDC Priority (New)

TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD

TBD
1
2
2
3
3
1
3
2
2
2
2
2
2
3
2
3
3
2
1
3
3
3
3
3
3

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
Mother-Infant Case ID Linkage
Mother's Last Menstrual Period Before
Delivery
Pregnancy Complications
Pregnancy Outcome
Newborn Complications
Other Arboviral Disease Transmission Mode

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?
Mother and infant case IDs
Mother's last menstrual period (LMP) before delivery
Complications of pregnancy
Pregnancy outcomes
Compliations for newborn
Other Arboviral unusual and rare disease transmission modes

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
Blood Recipient/Blood Transfusion
Blood Donor
Mother's Local Record ID

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)
In the year before symptom onset or diagnosis, did the subject receive a blood
transfusion?
In the year before symptom onset or diagnosis, did the subject donate blood?
Provide the local record ID used for reporting mother's case (DE Identifier "N/A:
OBR-3" in the Generic portion of the message). This will be used for linking the
reported congenital case to the mother's reported case.

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

CDC Priority (Legacy)

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
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
N/A

CDC Priority (New)

3

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 available
Clinical Presentation
Clinical Presentation Indicator
Date of Clinical Presentation
Medication Administered
Medication Administered Dose
Date Treatment or Therapy Started
Treatment Duration
Type of animal
Animal Ownership
Type of contact
Country of Product Acquisition
Disease Presentation
Food Product consumed
Contact Type
Similar Illness Contact
Physician Name
Physician Phone
Treatment Drug Indicator
Antibiotic dose units
Medication Stop Date
International Destination(s) of Recent
Travel
Travel State

Travel County
Specimen Collected Prior to Therapy

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 available for further testing?
Clinical presentation associated with the illness being reported
Indicator for associated clinical presentation
The date and time, if available, of onset of clinical presentation
Name of antibiotic administered to subject/patient for this illness
Dose of the antibiotic received
Date the treatment or therapy was started
Prescribed duration (in days) of antibiotic treatment
What type of animal did the patient have contact with, or acquire food products from?
Who owns the animals?
What type of activity was the case/patient engaged in that led to contact with the
animal(s)?
Where was the food product acquired?
The duration in which the disease presented
What type of animal-based food product did the patient consume?
If linked to confirmed case or contact with similar illness or signs and symptoms,
indicate type of contact.
Did the case/patient know anyone else with a similar illness?
Name of the physician or clinician who diagnosed and/or treated the subject
Phone number of the patient's clinician/provider of care
Were antimicrobials prescribed or administered to the subject for this illness or following an
exposure?
Dose units of the antimicrobial prescribed or administered
What was the date that the case patient stopped taking antimicrobials
List all international destination (country) traveled to during six months before symptom onset
or diagnosis
List all domestic destination (state) traveled to during six months before symptom onset or
diagnosis.

List all intrastate destination (county) traveled to during six months before symptom onset or
diagnosis.
Was the specimen for culture collected prior to antimicrobial therapy?

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

CDC Priority (Legacy)

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
TBD
PHVS_YesNoUnknown_CDC
N/A
TBD
N/A
N/A
N/A
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
N/A
N/A
PHVS_YesNoUnknown_CDC
PHVS_UnitsOfMeasure_CDC
N/A
PHVS_Country_ISO_3166-1
PHVS_State_FIPS_5-2

PHVS_County_FIPS_6-4
PHVS_YesNoUnknown_CDC

CDC Priority (New)

TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
3
3
2
2
3
1
2

3
2

Label/Short Name

Reported symptoms and signs of illness
Travel in 10 days prior to illness
Consumption of undercooked/ raw meat
Consumption of undercooked/ raw poultry
Drinking untreated water
Contact with untreated recreational water
Consumption of raw milk or unpasteurized dairy
Contact with pets, farm animals with Campylobacter
species
Contact with confirmed/probable case of
Campylobacteriosis
Consumption or exposure to implicated vehicle
WGS (Whole-Genome Sequencing) ID
Probable – Laboratory Diagnosed
Probable – Epi Linked
PulseNet ID
Travel State
International Destination(s) of Recent Travel
Date of Arrival to Travel Destination
Date of Departure from Travel Destination
Reason for travel related to current illness

Description

Symptoms and signs associated with illness
Did the case have travel outside of the U.S. in the 10 days before the illness began?
Did the case eat undercooked or raw meat before the illness began?
Did the case eat undercooked or raw poultry before the illness began?
Did the case drink untreated water before the illness began?
Did the case have contact with untreated recreational water before the illness began?
Did the case consume raw milk or unpasteurized dairy before the illness began?
Did the case have contact with pets or farm animals from which Campylobacter species were isolated?
Did the case have contact with another probable or confirmed case of Campylobacteriosis?
Did the case consume or have exposure to a vehicle implicated in an outbreak or a location in which an
implicated food vehicle was prepared or eaten?
The identifier used in PulseNet for the whole genome sequenced isolate that corresponds to the reported
case
Probable case is laboratory diagnosed
Probable case is epi linked
State lab ID submitted to PulseNet
Domestic destination, state(s) traveled to
International destination or countries the patient traveled to
Date of arrival to travel destination
Date of departure from travel destination
Reason for travel related to current illness

Value Set Code. Search in PHIN VADS using CDC
the following link
Priority
(https://phinvads.cdc.gov/vads/SearchHom (Legacy)
e.action)

PHVS_YesNo_HL7_2x
PHVS_YesNo_HL7_2x
N/A
PHVS_State_FIPS_5-2
PHVS_Country_ISO_3166-1
N/A
N/A
PHVS_TravelPurpose_FDD

CDC
Priority
(New)

P
P
1
3
3
3
3
3

Label/Short Name

Description

Previously Counted Case

Was patient previously counted as a
colonization/screening case?

Previously Reported State Case
Number

If patient was previously counted as a
colonization/screening case or a CP-CRE case, please
provide the related case ID(s)

Tracheostomy Tube at Specimen
Collection

Did patient have a tracheostomy tube at the time of
specimen collection?

Ventilator Use at Specimen Collection Was patient on a ventilator at the time of specimen
collection?
Long-term Care Resident
Type of Long-term Care Facility

Did the patient have a stay in a long-term care facility in
the 90 days before specimen collection date?
If patient had a stay in a long-term care facility in the 90
days before specimen collection date, indicate the type of
long-term care facility.

Healthcare Outside Resident State

Indicate if the patient received overnight healthcare within
the United States, but outside of the patient's resident
state in the year prior to the date of specimen collection.

Travel Outside USA Prior to Illness
Onset within Program Specific
Timeframe

Did the patient travel internationally in the past 1 year
from the date of specimen collection?

International Destination(s) of Recent List the names of the country(ies) outside of the United
Travel
States the patient traveled to in the year prior to the date
of specimen collection, if the patient traveled outside of
the United States during that time.

Healthcare Outside USA

Indicate if the patient received overnight healthcare
outside of the United States in the year prior to the date of
specimen collection.

Country(ies) of Healthcare Outside USA List the names of the country(ies) outside of the United
States where the patient received overnight healthcare in
the year prior to the date of specimen collection, if the
patient received overnight healthcare outside of the
United States during that time.
Type of Location Where Specimen
Collected

Indicate the physical location type of the patient when the
specimen was collected

County of Facility

County of facility where specimen was collected

State of Facility

State of facility where specimen was collected

Infection with Another MDRO

Does the patient have infection or colonization with
another MDRO?
If patient has infection or colonization with another
MDRO, indicate the MDRO.

Co-infection Type
State Lab specimen ID
WGS ID Number

State lab specimen ID
NCBI SRA Accession number (SRX#) We would describe this
as: The accession number generated by NCBI’s Sequence
Read Archive when sequence data are uploaded to NCBI.
This provides both the sequence data and metadata on
how the sample was sequenced.

Value Set Code. Search in PHIN VADS using the CDC Priority
following link
(https://phinvads.cdc.gov/vads/SearchHome.a
ction)
PHVS_YesNoUnknown_CDC
P
N/A

P

PHVS_YesNoUnknown_CDC

P

PHVS_YesNoUnknown_CDC

P

PHVS_YesNoUnknown_CDC

P

PHVS_LongTermCareFacilityType_C.auris

P

PHVS_YesNoUnknown_CDC

P

PHVS_YesNoUnknown_CDC

P

PHVS_Country_ISO_3166-1

P

PHVS_YesNoUnknown_CDC

P

PHVS_Country_ISO_3166-1

P

PHVS_SpecimenCollectionSettingType_C.auris P
PHVS_County_FIPS_6-4

P

PHVS_State_FIPS_5-2

P

PHVS_YesNoUnknown_CDC

P

PHVS_TypeCoInfection_C.auris

P

N/A
N/A

P
P

Label/Short Name

Description

Smoking status

Current smoker (yes, no, unknown)

Source of data for case ascertainment

*Hospital/emergency department
*Poison control center
* Laboratory report
*Death certificate
*Provider/medical examiner report

Carboxyhemoglobin (COHb) level
Intent

Laboratory test result (%)
*Intentional
*Unintentional

Primary Language
Marital Status

What is the patient's primary language?
What is the patient's current marital status?
Indicate the highest degree or level of school
Education
completed at the time of the event.
Does the patient have a poison control record
Poison Control Center Record
indicating exposure to carbon monoxide?
If patient has a poison control record, select the
Outcome of Poison Control Center Record outcome identified in the Poison Control Center
Record.
If patient has a poison control record, indicate
Treatment Management Type
how the care was managed.
Workers Compensation Record

Type of Workers Compensation Claim

Fire Related Exposure
Power Outage Event
Extreme Weather

Does the patient have a worker's compensation
record with a finding, problem, diagnosis or
other indication of exposure to carbon
monoxide or carbon monoxide poisoning?
Indicate the type of claim if patient has a
worker's compensation claim with a finding,
problem, diagnosis or other indication of
exposure to carbon monoxide or carbon
monoxide poisoning.
Was the carbon monoxide exposure related to
a fire?
Was the carbon monoxide exposure related to
a power outage?
Was the carbon monoxide exposure related to
an extreme weather event?

Identify the extreme weather event(s)
Extreme Weather Type
occurring when the patient was exposed to
carbon monoxide.
Immediately before or during the extreme
weather event, did patient hear or read about
Warning Announcement
any warnings on the danger of carbon
monoxide poisoning?
If patient was physically and temporally
Exposure Source
associated with a CO-emitting source, specify
the source.
If the exposure source is generator, where was
Generator Location
it placed while it was running?
If the exposure source was a generator, how
many feet was the generator placed from the
Generator Distance
(house/attached garage/detached garage or
other location of event)?
Patient was in a location where a carbon
Carbon Monoxide Alarm Present
monoxide alarm was present.
Carbon Monoxide Alarm Sounded
The carbon monoxide alarm sounded.
Exposure to an elevated level of CO based on a
Carbon Monoxide Elevated Exposure
dedicated or multi-gas meter/instrument (e.g.,
fire department measurement)?
Air concentration of CO Level in parts per
Air Concentration of CO Level (PPM)
million (PPM) at exposure site.
If air concentration of CO level was taken,
Person/Organization Taking CO Reading
indicate the person or organization taking the
CO reading.
What was the date and time, if known, of the
Date of Reading
CO reading?
Exposure Site Category
Categorize the location of exposure.
If a public setting where the exposure occurred,
Public Site of Exposure
please indicate specific site.
If a residential setting where the exposure
Residential Site of Exposure
occurred, please indicate specific site.
Patient was present and exposed in the same
event as that of a carbon monoxide poisoning
Epi-Linked
case.
Please provide the date and time, if known, of
Date and Time of Incident
the carbon monoxide incident.
Street address of the location or establishment
Address of Establishment Where Exposure where the carbon monoxide exposure
Occurred
occurred. Please provide street, city, county,
state, and zip code.
City of the location or establishment where the
City of Establishment Where Exposure
carbon monoxide occurred.
Occurred

State of the location or establishment where
State of Establishment Where Exposure
the carbon monoxide occurred.
Occurred
Zip Code of Establishment Where Exposure Zip code of the location or establishment where
the carbon monoxide occurred.
Occurred
County of Establishment Where Exposure County of the location or establishment where
the carbon monoxide occurred.
Occurred
Event Notes
Description of incident.
Total number of exposed persons (including
Number of Exposed Cases
case patient).
Average Number of Cigarettes Smoked per During the past 30 days, please specify the
average number of cigarettes smoked per day.
Day
There are 20 cigarettes per pack.
Marijuana Smoking Status
Does the patient currently smoke marijuana?
Type of other substance used (e.g., e-cigarette
Other Substance
tobacco, e-cigarette THC)
Underlying Condition(s)
Select the patient's preexisting condition(s).
Signs and symptoms associated with the carbon
Signs and Symptoms
monoxide exposure or poisoning.
ICD Codes List
ICD Codes in patient's report.
Was patient treated for carbon monoxide
Treatment Provided
exposure?
Treatment Type
Specify the treatment type.
Treatment Location
Where did the patient receive treatment?
Treatment Date
Provide the date of treatment.
Is the patient's carbon monoxide exposure
Occupation Related to Exposure
related to their current occupation?
Work Site of Exposure
If a work setting where the exposure occurred,
please indicate specific site.

Value Set Code. Search in PHIN VADS using the CDC
following link
Priority
(https://phinvads.cdc.gov/vads/SearchHome.acti (Legacy)
on)

CDC
Priority
(New)

P
https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7749

P
https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7891
N/A

P

https://phinvads.cdc.gov/vads/ViewValueSet.action?
P
oid=2.16.840.1.114222.4.11.7876

PHVS_Language_ISO_639-2_Alpha3
PHVS_MaritalStatus_HL7_2x

P
P

PHVS_Education_CO

P

PHVS_YesNoUnknown_CDC

P

PHVS_PoisonControlCenterRecord_CO

P

PHVS_TreatmentSite_CO

P

PHVS_YesNoUnknown_CDC

P

PHVS_WorkersCompensationRecord_CO

P

PHVS_YesNoUnknown_CDC

P

PHVS_YesNoUnknown_CDC

P

PHVS_YesNoUnknown_CDC

P

PHVS_ExtremeWeatherType_CO

P

PHVS_YesNoUnknown_CDC

P

PHVS_ExposureSource_CO

P

PHVS_GeneratorLocation_CO

P

PHVS_GeneratorDistance_CO

P

PHVS_YesNoUnknown_CDC

P

PHVS_YesNoUnknown_CDC

P

PHVS_YesNoUnknown_CDC

P

N/A

P

PHVS_PersonOrgTakingReading_CO

P

N/A

P

PHVS_ExposureSiteCategory_CO

P

PHVS_SiteofExposure_CO

P

PHVS_ResidentialSiteofExposure_CO

P

PHVS_YesNoUnknown_CDC

P

N/A

P

N/A

P

N/A

P

PHVS_State_FIPS_5-2

P

N/A

P

N/A

P

N/A

P

N/A

P

TBD

P

PHVS_YesNoUnknown_CDC

P

TBD

P

PHVS_UnderlyingConditions_CO

P

PHVS_SignsandSymptoms_CO

P

PHVS_ICDCodesList_CO

P

PHVS_YesNoUnknown_CDC

P

PHVS_TreatmentType_CO
PHVS_TreatmentLocation_CO
N/A

P
P
P

PHVS_YesNoUnknown_CDC

P

TBD

2

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
Specify Different Exposure Window

PulseNet ID
WGS ID Number

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
If the epidemiologic exposure window used by the jurisdiction is different
from that stated in the exposure questions, specify the time interval in days
here. Otherwise, leave blank.
State lab ID submitted to PulseNet
Whole Genome Sequencing (WGS) ID Number

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

CDC Priority (Legacy)

N/A

N/A
N/A

P

CDC Priority (New)

1
1

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 pregnanc
Were any of the children living in the household immunized with Rubella-containing v
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 fi
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 rubella-containing vaccine?
Source of mother's Rubella-containing vaccine information
Source of mother's rubella-containing vaccine
Vaccine Administered
Vaccine Manufacturer
Vaccine Lot Number
Vaccine Administered Date
US Acquired
Specimen from mother or infant
At the time of cessation of pregnancy, what was the age of the fetus (in weeks)?
Birth State
Mother's Country of Residence
Mother's pre-pregnancy serological test date.
Mother's pre-pregnancy serological test interpretation.
Pregnancy outcome
Number of doses received on or after 1st birthday
Date of last dose prior to illness onset

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
Is the specimen from the mother or infant?
If applicable, at the time of cessation of pregnancy, what was the age of the fetus (in
weeks)?
State where the subject was born
What is the mother's country of residence?
If pre-pregnancy serological testing was performed, what was the date of mother's
pre-pregnancy serological test?
If pre-pregnancy serological testing was performed, what was the interpretation of
mother's pre-pregnancy serological test?
What was the outcome of the current pregnancy
The number of vaccine doses against this disease which the mother received on or
after their first birthday
Date of mother's last vaccine dose against this disease prior to illness onset

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

Description

RECTYPE

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?

Maternal Local
Record ID
Maternal
Notification
Reporting
Jurisdiction

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

CDC
Priority
(New)

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

Label/Short Name
Type of case
State lab isolate id
Phenotypic Test Method
Phenotypic Test Result
Genotypic Test Name
Genotypic Test Result
County of facility
State of facility
Travel Outside USA Prior to
Illness Onset within
Program Specific Timeframe
International Destination(s)
of Recent Travel
Healthcare Outside USA
Country(ies) of Healthcare
Outside USA
Gene Identifier
Previously Counted Case
Previously Reported State
Case Number
WGS ID Number

Description
Type of case (i.e., was case identified based on testing of a clinical specimen or screening specimen)
Lab isolate identifier from public health lab for mechanism testing
Phenotypic Test Name (phenotypic methods for carbapenemase production)
Result of Phenotypic test
Test performed to identify carbapenemase (molecular methods for resistance mechanism)
Result of test to identify carbapenemase
County of facility where specimen was collected
State of facility where specimen was collected
Did the patient travel internationally in the past 1 year from the date of specimen collection?
This data element is used to capture the names of the country(ies) outside of the United States the patient
traveled to in the year prior to the date of specimen collection, if the patient has traveled outside of the
United States during that time.
This data element is used to capture if the patient received healthcare outside of the United States in the
year prior to the date of specimen collection.
This data element is used to capture the names of the country(ies) outside of the United States where the
patient received healthcare in the year prior to the date of specimen collection, if the patient traveled
outside of the United States during that time.
Gene identifier
Was patient previously counted as a colonization/screening case?
If patient was previously counted as colonization/screening case please provide related case ID(s)
NCBI SRA Accession number (SRX#) We would describe this as: The accession number generated by NCBI’s
Sequence Read Archive when sequence data are uploaded to NCBI. This provides both the sequence data
and metadata on how the sample was sequenced.

Value Set Code. Search in PHIN VADS using the following link
(https://phinvads.cdc.gov/vads/SearchHome.action)
N/A
N/A
N/A
N/A
N/A
N/A
PHVS_County_FIPS_6-4
PHVS_State_FIPS_5-2

CDC
Priority
P
P
P
P
P
P
O
O

PHVS_YesNoUnknown_CDC

P

PHVS_Country_ISO_3166-1

P

PHVS_YesNoUnknown_CDC

P

PHVS_Country_ISO_3166-1

P

PHVS_GeneName_CP-CRE
PHVS_YesNoUnknown_CDC

P
P

N/A

P

N/A

P

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
Specify Different Exposure Window

CryptoNet ID
WGS ID Number
Travel State
International Destination(s) of
Recent Travel
Date of Arrival to Travel Destination
Date of Departure from Travel
Destination
Reason for travel related to current
illness

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)
If the epidemiologic exposure window used by the jurisdiction is different from that
stated in the exposure questions, specify the time interval in days here. Otherwise,
leave blank.
Unique CryptoNet ID (formed by concatenating [Case Year]-[State Lab ID]-[Specimen
Type]-[Reporting State]-[Reporting Country]) where Specimen Type is: ES for
Environmental, HS for Human, or AS for Animal.
Whole Genome Sequencing (WGS) ID Number
Domestic destination, state(s) traveled to
International destination or countries the patient traveled to
Date of arrival to travel destination
Date of departure from travel destination
Reason for travel related to current illness

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)

CDC Priority (Legacy)

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)

N/A

N/A

N/A
PHVS_State_FIPS_5-2
PHVS_Country_ISO_3166-1
N/A
N/A
PHVS_TravelPurpose_FDD

P

CDC Priority (New)

1

1
3
3
3
3
3

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
Travel
Travel State
Medication Administered
Performing Laboratory Type
Other Organism from Specimen
Specify Different Travel Exposure
Window
Did The Case Travel Domestically
Prior To Illness Onset?
Specify Different Exposure Window

Reason for travel related to current
illness

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)
In the two weeks before onset of illness, did the case-patient travel out of their state
or US?
Domestic destination or state(s) the case-patient traveled to in the two weeks before
onset of illness
What treatment did the case-patient receive?
Performing laboratory type
If other non-Cyclospora organism(s) identified from stool specimen(s), indicate the
organism
If the travel exposure window used by the jurisdiction is different from that stated in
the travel exposure questions, specify the time interval in days here. Otherwise, leave
blank.
Did the case patient travel domestically within program specific timeframe?
If the epidemiologic exposure window used by the jurisdiction is different from that
stated in the exposure questions, specify the time interval in days here. Otherwise,
leave blank.
Reason for travel related to current illness

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

CDC Priority (Legacy)

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

N/A

P

PHVS_YesNoUnknown_CDC

P

N/A

P

PHVS_TravelPurpose_FDD

CDC Priority (New)

3

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?
Bacterial Infection Syndrome
Pregnancy Status at the Time of First
Positive Culture
Pregnancy Outcome
Gestational Age
Birth Weight
Birth Weight Units
Previous Contact With Hib Disease
Hib Contact Type
Previous Contact With Non-b or
Nontypeable H. influenzae Case
Non-b or Nontypeable Contact Type
Recurrent Disease with Same
Pathogen

Previous State ID (Recurrent Case)
Case Report Form Status
Illness Onset Age
Illness Onset Age Units
Residence
Premature Infant
Epi-Linked to a LaboratoryConfirmed Case
ABCs Case
ABCs State ID
Laboratory Testing Performed
Laboratory Confirmed
Test Manufacturer
Lab Accession Number
Did the Subject Ever Receive a
Vaccine Against This Disease
Date of Last Dose Prior to Illness
Onset
Vaccination Doses Prior to Onset
Vaccine History Comments
Age at Vaccination
Age at Vaccination Units
Vaccine History Information Source

Vaccine Information Source Indicator
Susceptibility Test

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.
Types of infection caused by organism
At the time of first positive culture, was the patient pregnant or postpartum? (The
postpartum period is defined as the 30 days following a delivery or miscarriage)
If pregnant or postpartum, what was the outcome of fetus?
If patient <1 month of age, indicate gestational age (in weeks)
If patient <1 month of age, indicate birth weight
Birth Weight Units
Is there a known previous contact(s) with Hib disease within the preceding two
months?
Type of previous contact(s) with Hib disease within the preceding two months.
Did patient have known previous contact(s) with a non-b or nontypeable case of H.
influenzae disease within the preceding 2 months?
Specify type of contact(s) with non-b or nontypeable case of H. influenzae
this case have recurrent disease with the same pathogen? (For Streptococcus
pneumoniae, the specimen from the current case must have been isolated 8 or more
days after any previous case due to the same pathogen. For all other pathogens, the
specimen from the current case must have been isolated 30 or more days after any
previous case due to the same pathogen.)
StateID of 1st occurrence for this pathogen and person.
Case Report Form Status
Illness onset age
Illness onset age units
Where was the patient a resident at time of initial culture?
Premature at birth (for children ≤2 years old)
Is this case epi-linked to a laboratory-confirmed case?
ABCs case?
ABCs State ID
Was laboratory testing done to confirm the diagnosis?
Was the case laboratory confirmed?
Test Manufacturer
Lab Accession Number (including CDC Lab ID)
Did the subject ever receive a vaccine against this disease?
Date of last vaccine dose against this disease prior to illness onset
Number of vaccine doses against this disease prior to illness onset
Vaccine History Comments
The persons age at the time the vaccine was given
The age units of the person at the time the vaccine was given
What sources were used for vaccination history?

Vaccination History Information Source Indicator
Was any susceptibility data available?

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

CDC Priority

PHVS_YesNoUnknown_CDC
PHVS_Country_ISO_3166-1
PHVS_YesNoUnknown_CDC
PHVS_InfectionType_RIBD
PHVS_PregnacyStatus_RIBD

P
P

PHVS_FetalOutcome_RIBD
N/A
N/A
PHVS_WeightUnit_UCUM
PHVS_YesNoUnknown_CDC

P
P
P
P
P

PHVS_ContactType_RIBD
PHVS_YesNoUnknown_CDC

P
P

PHVS_ContactType_RIBD

P

PHVS_YesNoUnknown_CDC

P

N/A
PHVS_FormStatus_RIBD
N/A
PHVS_AgeUnit_UCUM
PHVS_ResidenceLocation_RIBD
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

P
P
P
P
P
P
P

PHVS_YesNoUnknown_CDC
N/A
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
N/A
N/A
PHVS_YesNoUnknown_CDC

P
P
P
P
P
P
P

N/A

P

N/A
N/A
N/A
PHVS_AgeUnit_UCUM
PHVS_InformationSource_RIBD

P
P
P
P
P

PHVS_YesNoUnknown_CDC

P

PHVS_YesNoUnknown_CDC

P

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
History of Previous Illness
Date of Previous Illness
Number of doctors seen
Biopsy Performed
Biopsy Results
Biopsy Interpretation
Date of Previous Biopsy
Previous Residence
Relation to Known or Suspected
Contact
Household contacts Examined
Additional Cases
Skin Smear Interpretation
Date of Skin Smear
Medication Administered

Previous Treatment
Previous Treatment Duration
Date Treatment or Therapy Started
Contacts Received Prophylaxis
Number of Household Contacts
Family/Household Contacts
Previously Diagnosed
Number of Family/Household
Previously Diagnosed
Relationship to Known or Suspected
Contact
Additional Cases
Patient Status
History of Post-exposure Prophylaxis
Location of Initial Diagnosis
Medication Stop Date
Post-exposure or Treatment
Post-Exposure Prophylaxis
Medication
History of Treatment for Latent or
Active TB
Medication Frequency
Medication Frequency Unit
Medication Duration
Medication Duration Units
Medication Recipient
Medication Dose
Medication Dosage Unit

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?
Was the patient previously diagnosed with Hansen's disease?
Date of previous Hansen's Disease diagnosis
How many doctors has the patient seen for this problem?
Was a biopsy performed on the patient as a result of Hansen's disease?
TBD
Indicate the results of the biopsy
If biopsy was performed on the patient, indicate the date of biopsy.
List all places in the US. and all foreign countries a PATIENT resided (including military
service) BEFORE leprosy was diagnosed.
TBD
Have any household contacts of the patient been examined
TBD
If skin smears were performed, please select the results.
Date of Skin Smear
What antibiotic was administered to the patient for Leprosy

Was the patient previously treated for Hansen's Disease
If the patient was previously treated, how many months was the patient treated.
Date the treatment was initiated
Have any household contacts of the patient started prophylaxis?
Total number of known or suspected household contacts.
Have any family members or household contacts been previously diagnosed with HD
List number of diagnosed previously with Hansen's Disease.
If answer yes to previous question regarding family member diagnosed, please check
relationship.
If household contacts of the patient were examined, were any additional cases found
Indicate the patient's case status
Does the case patient have a history of being of post-exposure prophylaxis for
Hansen's disease or tuberculosis (TB)
Indicate the location of the initial diagnosis of Hansen's Disease
What was the date that the case patient stopped taking antimicrobials
Indicates if medication received is for post-exposure or Hansen's treatment.
If answer is yes to the previous question regarding household contacts of the patient
receiving prophylaxis, please specify PEP
Does the case patient have a history of being on treatment for latent or active TB?
Frequency of medication administered for this condition.
Unit of measure for the frequency of medication administered (e.g. daily, weekly,
monthly).
Duration of medication treatment or post-exposure prophylaxis.
Unit of measure for the duration of medication administered (e.g. days, weeks,
months).
Specify recipient of medication for Hansen's disease (e.g. household contact, case
subject).
Dosage of medication received.
Unit of measure for medication received (e.g. milligram [mg], milligram/kilogram
[mg/kg])

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

CDC Priority (Legacy)

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
Yes No Unknown (YNU)

N/A
Yes No Unknown (YNU)
Yes No Unknown (YNU)

TBD
TBD
N/A
TBD
TBD
Yes No Unknown (YNU)

TBD
TBD
TBD
TBD

Yes No Unknown (YNU)

N/A
N/A
Yes No Unknown (YNU)

N/A
Yes No Unknown (YNU)

N/A
N/A
Yes No Unknown (YNU)

TBD
Yes No Unknown (YNU)

PHVS_LocationofInitialDiagnosis_Hansen
N/A
TBD
N/A
PHVS_YesNoUnknown_CDC
N/A
TBD
N/A
TBD
TBD
N/A
TBD

CDC Priority (New)

TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD

TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
3
2
2
2
3
2
2
2
2
1
2
2

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
Elevated Hematocrit (>50)
Elevated Creatinine (>1.2 mg/dL)
Proteinuria
Hematuria
Exposure occurred from pet rodent
Street address

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 distress sy
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
Was Elevated Hematocrit >50?
Was Elevated Creatinine >1.2 mg/dL?
Was Proteinuria detected?
Was Hematuria detected?
Did exposure occur from a pet rodent?
What is the patient’s street address?

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
Maternal HBeAg result, date
Maternal HBV DNA (or genotype),
result, date
Maternal Alanine aminotransferase
(ALT)
Maternal antiviral therapy, if any
Maternal Coinfection with human
immunodeficiency virus or hepatitis
C virus

Maternal State/Territory of
residence at time of infant’s
diagnosis
Infant Birthweight
Infant Time of birth (military time)
Infant State/Territory of birth
HCV RNA (NAAT) test results
HCV genotype test results
HCV antigen test results
hepatitis A RNA
Date of hepatitis A RNA test
Total bilirubin
Date of bilirubin test
Experienced homelessness
CSTE Case Definition
Information Source for Data
Signs and Symptoms
Signs and Symptoms Indicator
Date of Symptom Onset
Date of Jaundice Onset
Case Patient a Healthcare Worker

Patient Epidemiological Risk Factors

Patient Epidemiological Risk Factors
Indicator
Contact Type
Men who have Sex with Men
Multiple Sex Partners
Previous STD History
Antiviral Medication

Birth Weight (unit)
Vaccinated within 12 Hours of Birth

Treatment within 12 Hours of Birth

Seroconversion

Occupation and Industry Category

Occupation and Industry Category
Indicator
Positive Results 6 Months Apart

Mother's Local Record ID

Mother Nucleic Acid Test

Mother Nucleic Acid Test Result

Mother Nucleic Acid Test Viral Load
Mother HBeAg Test

Mother HBeAg Test Result
Infant HBsAg Test

Infant HBsAg Test Result
Infant HBsAg Positive Date

Infant HBeAg Test

Infant HBeAg Test Result
Infant HBeAg Positive Date
Infant HBV DNA Test

Infant HBV DNA Test Result
Infant HBV DNA Positive Date
Infant anti-HCV Test

Infant anti-HCV Test Result
Infant anti-HCV Positive Date
Infant Nucleic Acid Test

Infant Nucleic Acid Test Result

Infant Nucleic Acid Positive Date
Infant HCV Antigen Test

Infant HCV Antigen Test Result
Infant HCV Antigen Positive Date
Tissue or organ transplant

Non-injection Drug Use

Specimen From Mother or Infant
Transplant Date
Subject of Lab Test Performed

Previously Infected Individual

Previous State Case Number

Other Reported Case(s)

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.)
Maternal HBeAg result, date
Maternal HBV DNA (or genotype), result, date
Maternal Alanine aminotransferase (ALT)
Maternal antiviral therapy, if any
Maternal Coinfection with human immunodeficiency virus or hepatitis C virus

Maternal State/Territory of residence at time of infant’s diagnosis

Infant Birthweight
Infant Time of birth (military time)
Infant State/Territory of birth
HCV RNA (NAAT) test results and timing of test performance
HCV genotype test results and timing of test performance
HCV antigen test results and timing of test performance
Nucleic acid amplification test (NAAT; such as PCR or genotyping) for hepatitis A virus
RNA
Date of hepatitis A RNA test
Total bilirubin levels
Date of bilirubin test
In the 2-6 weeks prior to symptom onset, was the patient homeless?
Did the patient meet the CSTE case definition(s) for any of the following in a previous
reporting year? (select all that apply)
Source of Laboratory Test: (select all that apply)
Signs and symptoms associated with the illness being reported
Response for each of the signs and symptoms.
The date and time, if available, of the symptom onset (clinical manifestation)
What was the date of jaundice onset?
Was the patient employed as a healthcare worker during the TWO WEEKS prior to
onset of symptoms to ONE WEEK after onset of JAUNDICE? (If no jaundice, use two
weeks after onset of symptoms)
Exposed risk factors for the patient - Please provide a response for all risk factors in the
value set with an associated indicator.
In the 15 to 50 days before symptom onset date for hepatitis A.
In the 60 to 150 days (2 to 5 months) before symptom onset date for hepatitis B.
In the 14 to 182 days (2 weeks to 6 months) before symptom onset date for hepatitis
C.
Provide a response for each value in the patient epidemiological risk factors value set.
If the patient was a contact of a person with confirmed or suspected hepatitis virus
infection, was the contact: (select all that apply)
Was the patient a man who reported sexual activity with men?
Did the patient report multiple sex partners?
Was the patient diagnosed with a sexually transmitted disease?
Did the gestational parent receive hepatitis B antiviral therapy during the third
trimester of pregnancy?
The patient's birth weight units
Did the patient receive the hepatitis B vaccine within 12 hours of birth?

Did the patient receive the hepatitis B immune globulin within 12 hours of birth?

If hepatitis B case, did the patient meet the acute hepatitis B seroconversion criteria?
(i.e., documented negative HBsAg laboratory test result within 6 months prior to a
positive test [HBsAg, HBeAg, or nucleic acid test for HBV DNA (including qualitative,
quantitative, and genotype testing)] in someone without a prior diagnosis of HBV
infection)
If hepatitis C case, did the patient meet the acute hepatitis C seroconversion criteria?
(e.g., documented negative anti-HCV followed within 12 months by a positive anti-HCV
test; or documented negative anti-HCV or negative HCV detection test [in someone
without a prior diagnosis of HCV infection] followed within 12 months by a positive
HCV detection test; or, in the case of presumed reinfection, at least two sequential
negative HCV detection tests [in someone with a prior diagnosis of HCV infection]
followed by a positive HCV detection test).
Was the patient employed as a food handler or a healthcare worker during the TWO
WEEKS prior to onset of symptoms to ONE WEEK after the onset of JAUNDICE? (If no
jaundice, use two weeks after onset of symptoms)
Please indicate for each occupation:

Did the patient have two positive results at least 6 months apart from any of the
following tests: (1) HBsAg; (2) nucleic acid test for HBV DNA (including qualitative,
quantitative, and genotype testing); (3) HBeAg? (Any combination of these positive
tests performed at least 6 months apart is acceptable)
Provide the local record ID used for reporting mother's case of hepatitis (DE Identifier
"N/A: OBR-3"). This will be used for linking the reported perinatal case to the mother's
reported hepatitis case.
For hepatitis B, perinatal, did the gestational parent receive nucleic acid testing for
HBV DNA during pregnancy?
For hepatitis C, perinatal, did the gestational parent receive nucleic acid testing for
HCV RNA (including qualitative or quantitative PCR, or genotype testing) during
pregnancy?
For hepatitis B, perinatal, if the gestational parent received nucleic acid testing for HBV
DNA during pregnancy, then indicate the result.
For hepatitis C, perinatal, if the gestational parent received nucleic acid testing for HCV
RNA (including qualitative or quantitative PCR, or genotype testing) during pregnancy,
then indicate the result.
If the gestational parent received nucleic acid testing for HBV DNA during pregnancy,
then indicate the viral load:
Did the gestational parent receive HBeAg testing during pregnancy?

If the gestational parent received HBeAg testing during pregnancy, indicate the result.
Did the patient receive an HBsAg test between age 1–24 months (only if ≥4 weeks after
the last dose of hepatitis B vaccine)?
If the patient received an HBsAg test between age 1–24 months (only if ≥4 weeks after
the last dose of hepatitis B vaccine), indicate the result.
If positive, then indicate the date of the first positive HBsAg test between age 1-24
months.

Did the patient receive an HBeAg test between age 9–24 months?

If the patient received an HBeAg test between age 9–24 months, indicate the result.
If positive, then indicate the date of the first positive HBeAg test between age 9-24
months.
Did the patient receive an HBV DNA test between age 9–24 months?

If the patient received an HBV DNA test between age 9–24 months, indicate the result.
If detected/positive, then indicate the date of the first positive HBV DNA test between
age 9-24 months.
Did the patient receive an anti-HCV test between age 18-36 months?

If the patient received an anti-HCV test between age 18-36 months, indicate the result.
If positive, then indicate the date of the first positive anti-HCV test between age 18-36
months.
Did the patient receive nucleic acid testing for HCV RNA (including qualitative or
quantitative PCR, or genotype testing) between age 2-36 months?
If the patient received nucleic acid testing for HCV RNA (including qualitative or
quantitative PCR, or genotype testing) between age 2-36 months, indicate the result.
If detected/positive, then indicate the date of the first positive nucleic acid test for
HCV RNA between age 2-36 months.
Did the patient receive HCV antigen test between age 2-36 months?

If the patient received HCV antigen test between age 2-36 months, indicate the result.
If positive, then indicate the date of the first positive HCV antigen test between age 236 months.
Did the patient receive tissue or organ transplant(s)?

Did the patient use non-injection drugs not prescribed by a doctor or engage in
nonmedical use of prescription drugs?
V1.0 only: During the 2-6 weeks prior to the onset of symptoms, did the subject inject
drugs not prescribed by a doctor?
Is the specimen from the gestational parent or the infant?
Date(s) of organ transplant(s).
Indication to specify whether the Lab Test Performed was for the mother or infant.

Did the subject meet the case definition for a previous case investigation of this
disease or condition?
If the subject previously met the case definition for the disease or illness, what was
the previously submitted sending system-assigned local ID (case ID) of the case
investigation with which the subject is associated?
Select all of the newly reported case(s) of the hepatitides confirmed within the
current reporting year other than the primary condition reported for this case
notification.

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

CDC Priority (Legacy)

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

PHVS_LabTestResultQualitative_CDC
N/A
N/A
N/A
PHVS_YesNoUnknown_CDC

P
P
P
P
P

TBD
TBD
TBD
Yes No Unknown (YNU)https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.888
N/A
N/A
Yes No Unknown (YNU)
https://phinvads.cdc.gov/vads/ViewValueSet.action?
oid=2.16.840.1.114222.4.11.888
TBD

Yes No Unknown (YNU)https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.888
TBD
Yes No Unknown (YNU)https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.888
Yes No Unknown (YNU)https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.888
Yes No Unknown (YNU)https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.888
Yes No Unknown (YNU)
https://phinvads.cdc.gov/vads/ViewValueSet.action?
oid=2.16.840.1.114222.4.11.888
TBD
Yes No Unknown (YNU)
https://phinvads.cdc.gov/vads/ViewValueSet.action?
oid=2.16.840.1.114222.4.11.888
Yes No Unknown (YNU)
https://phinvads.cdc.gov/vads/ViewValueSet.action?
oid=2.16.840.1.114222.4.11.888

Yes No Unknown (YNU)
https://phinvads.cdc.gov/vads/ViewValueSet.action?
oid=2.16.840.1.114222.4.11.888

TBD

Yes No Unknown (YNU)
https://phinvads.cdc.gov/vads/ViewValueSet.action?
oid=2.16.840.1.114222.4.11.888
Yes No Unknown (YNU)
https://phinvads.cdc.gov/vads/ViewValueSet.action?
oid=2.16.840.1.114222.4.11.888
N/A

Yes No Unknown (YNU)
https://phinvads.cdc.gov/vads/ViewValueSet.action?
oid=2.16.840.1.114222.4.11.888

TBD

TBD
Yes No Unknown (YNU)
https://phinvads.cdc.gov/vads/ViewValueSet.action?
oid=2.16.840.1.114222.4.11.888
TBD
Yes No Unknown (YNU)
https://phinvads.cdc.gov/vads/ViewValueSet.action?
oid=2.16.840.1.114222.4.11.888
TBD
N/A

Yes No Unknown (YNU)
https://phinvads.cdc.gov/vads/ViewValueSet.action?
oid=2.16.840.1.114222.4.11.888
TBD
N/A
Yes No Unknown (YNU)
https://phinvads.cdc.gov/vads/ViewValueSet.action?
oid=2.16.840.1.114222.4.11.888
TBD
N/A
Yes No Unknown (YNU)
https://phinvads.cdc.gov/vads/ViewValueSet.action?
oid=2.16.840.1.114222.4.11.888
TBD
N/A
Yes No Unknown (YNU)
https://phinvads.cdc.gov/vads/ViewValueSet.action?
oid=2.16.840.1.114222.4.11.888
TBD

N/A
Yes No Unknown (YNU)
https://phinvads.cdc.gov/vads/ViewValueSet.action?
oid=2.16.840.1.114222.4.11.888
TBD
N/A
Yes No Unknown (YNU)
https://phinvads.cdc.gov/vads/ViewValueSet.action?
oid=2.16.840.1.114222.4.11.888
Yes No Unknown (YNU)
https://phinvads.cdc.gov/vads/ViewValueSet.action?
oid=2.16.840.1.114222.4.11.888
PHVS_SpecimenFromMotherOrInfant_CRS
NA
PHVS_MotherInfantIndicator_NND

Yes No Unknown (YNU)

N/A

PHVS_NotifiableConditions_Hepatitis

CDC Priority
(New)

2
2
1
1
1
1

2

1
1
2
1
1
2

1
1

1

1

1

2

2

1

3

2

2
2

2
2

1
1
1

1
1
1

1
1
1

1
1
1

1

1
1

1
1
1

2

1
1
2
1

2

2

2

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
Clinical syndrome
Method(s) of laboratory testing
Name of CIDT test and manufacturer
CLIA number of laboratory
In Day Care
Underlying Condition(s)
Underlying Conditions Indicator
Illness Onset Age
Illness Onset Age Units
Hospital ICU
Residence
Pregnancy Status at the Time of First
Positive Culture
Pregnancy Outcome

Gestational Age
Birth Weight
Birth Weight Units
Premature Infant
Insurance
Epi-Linked to a LaboratoryConfirmed or Probable Case
ABCs Case
ABCs State ID
Recurrent Disease with Same
Pathogen

Previous State ID (Recurrent Case)
Laboratory Testing Performed
Laboratory Confirmed
Test Manufacturer
Lab Accession Number
Did the Subject Ever Receive a
Vaccine Against This Disease
Date of Last Dose Prior to Illness
Onset
Vaccination Doses Prior to Onset
Vaccine History Comments
Age at Vaccination
Age at Vaccination Units
Vaccine History Information Source
Vaccine Information Source Indicator
Susceptibility Test

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
Clinical diagnoses associated with a case of IPD
Type of laboratory test used to diagnose pneumococcal infection from a sterile site
isolate
Name of culture independent laboratory test used and manufacturer of the test
CLIA number of the laboratory that conducted the testing
Does this patient attend a day care facility?
Listing of underlying causes or prior illnesses
Underlying Conditions Indicator
Illness onset age
Illness onset age units
During any part of the hospitalization, did the subject stay in an Intensive Care Unit
(ICU) or a Critical Care Unit (CCU)?
Where was the patient a resident at time of initial culture?
At the time of first positive culture, was the patient pregnant or postpartum? (The
postpartum period is defined as the 30 days following a delivery or miscarriage)
If pregnant or postpartum, what was the outcome of fetus?

If patient <1 month of age, indicate gestational age (in weeks)
If patient <1 month of age, indicate birth Weight
Birth Weight Units
Premature at birth (for children ≤2 years old)
Insurance
Is this case Epi linked to a confirmed or probable case?
ABCs case?
ABCs State ID
Does this case have recurrent disease with the same pathogen? (For Streptococcus
pneumoniae, the specimen from the current case must have been isolated 8 or more
days after any previous case due to the same pathogen. For all other pathogens, the
specimen from the current case must have been isolated 30 or more days after any
previous case due to the same pathogen.)
StateID of 1st occurrence for this pathogen and person.
Was laboratory testing done to confirm the diagnosis?
Was the case laboratory confirmed?
Test Manufacturer
Lab Accession Number (including CDC Lab ID)
Did the subject ever receive a vaccine against this disease?
Date of last vaccine dose against this disease prior to illness onset
Number of vaccine doses against this disease prior to illness onset
Vaccine History Comments
The persons age at the time the vaccine was given
The age units of the person at the time the vaccine was given
What sources were used for vaccination history?
Vaccination History Information Source Indicator
Was any susceptibility data available?

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

CDC Priority

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

PHVS_YesNoUnknown_CDC
PHVS_UnderlyingConditions_RIBD
PHVS_YesNoUnknown_CDC
N/A
PHVS_AgeUnit_UCUM
PHVS_YesNoUnknown_CDC

P
P
P
P
P
P

PHVS_ResidenceLocation_RIBD
PHVS_PregnacyStatus_RIBD

P
P

PHVS_FetalOutcome_RIBD

P

N/A
N/A
PHVS_WeightUnit_UCUM
PHVS_YesNoUnknown_CDC
PHVS_InsuranceType_RIBD
PHVS_YesNoUnknown_CDC

P
P
P
P
P
P

PHVS_YesNoUnknown_CDC
N/A
PHVS_YesNoUnknown_CDC

P
P
P

N/A
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
N/A
N/A
PHVS_YesNoUnknown_CDC

P
P
P
P
P
P

N/A

P

N/A
N/A
N/A
PHVS_AgeUnit_UCUM
PHVS_InformationSource_RIBD
PHVS_YesNoUnknown_CDC

P
P
P
P
P
P

PHVS_YesNoUnknown_CDC

P

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
Illness Onset Age
Illness Onset Age Units

Accomodation Comments
Address of Healthcare Facility
Zip Code of Healthcare Facility
Healthcare Setting Exposure
Comments
Healthcare Facility Water
Management Program
Street Address of Assisted/Senior
Living Facility
Zip Code of Assisted/Senior Living
Facility
Assisted/Senior Living Facility
Comments
Assisted/Senior Living Facility Water
Management Program
Exposure
Exposure Indicator
Location of Exposure
Date(s) of Exposure
Recent Cruise Travel
Name of Cruiseline
Name of Ship
Cruise Departure City
Cruise Departure State
Cruise Departure Country
Date of Cruise Departure
Cruise Return City
Cruise Return State
Cruise Return Country
Date of Cruise Return
Cabin Number
Port of Call City
Port of Call Country
Port of Call State
Port of Call Date
CDC NORS Outbreak ID#
Did Underlying Condition(s) Exist
Underlying Condition(s)
Underlying Conditions Indicator
Titer Test Type
Test Manufacturer
Test Brand Name

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

Age at illness onset
Age units at illness onset

Comments or information about nights away from home not collected elsewhere
Street Address of healthcare facility visited by the patient in the 10 days before onset
Zip code of healthcare facility visited by the patient in the 10 days before onset
Comments or information about healthcare setting exposure not collected elsewhere
Did the healthcare facility have a water management program to reduce the risk of
Legionella growth and spread in place?
Street address of assisted/senior living facility visited/lived in by the patient during
exposure
Zip code of assisted/senior living facility visited/lived in by the patient during exposure
Comments or information about assisted/senior living facility exposure not collected
elsewhere
Did the assited/senior living facility have a water management program to reduce the
risk of Legionella growth and spread in place?
Was the patient exposed to any of the following during the 10 days prior to onset?
Exposure Indicator
Location of exposure (e.g. facility name, city , state)
Date(s) of exposure
In the 10 days before onset, did patient take a cruise?
Name of cruiseline patient sailed with
Name of ship patient sailed on
Cruise departure city
Cruise departure state
Cruise departure country
Cruise departure date
Cruise return city
Cruise return state
Cruise return country
Cruise return date
Patient's cruise ship cabin number
Port of call city
Port of call country
Port of call state
Date for port of call
CDC National Outbreak Reporting System (NORS) Outbreak ID#
Did the patient have any underlying causes or prior illnesses?
Listing of underlying causes or prior illnesses
Underlying conditions indicator
If this is a titer, indicate if this is an initial/acute or convalescent titer (Titer Test Type)
Test Manufacturer
Test Brand Name

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

CDC Priority

N/A
PHVS_AgeUnit_UCUM

P
P

N/A
N/A

P
P

N/A
N/A

P
P

PHVS_YesNoUnknown_CDC

P

N/A

P

N/A

P

N/A

P

PHVS_YesNoUnknown_CDC

P

PHVS_LegionellaExposure_RIBD
PHVS_YesNoUnknown_CDC
N/A
N/A
PHVS_YesNoUnknown_CDC
PHVS_CruiseLine_RIBD
N/A
N/A
PHVS_State_FIPS_5-2
PHVS_Country_ISO_3166-1
N/A
N/A
PHVS_State_FIPS_5-2
PHVS_Country_ISO_3166-1
N/A
N/A
N/A
PHVS_Country_ISO_3166-1
PHVS_State_FIPS_5-2
N/A
N/A
PHVS_YesNoUnknown_CDC
PHVS_UnderlyingConditions_RIBD
PHVS_YesNoUnknown_CDC
PHVS_TiterTestType_RIBD

P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P

N/A
N/A

P
P

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
Number of Weeks Gestation at Onset
of Illness
Pregnancy Adverse Outcome
Clinical Manifestation Indicator
Medication
Hospital Procedure
Sick Animal
Sick Animal Specified
Drinking or Bathing Usage
Treated Well Water or Rainwater
Flooding Location
Pre-existing conditions
Work Location State
Work Location City
Work Location Zip
Open Wounds

Type of Rodent
Highest Titer Serovar(s)
Contact with Sewage
Activity Type
Exposure Location City
Exposure Location State
Exposure Location Country
Exposure Location
Patient Address City
Immunocompromised Associated
Condition or Treatment
Days Missed Due to Illness
Container Lid
Rodent Location

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.
If subject was pregnant at time of illness onset, specify the number of weeks gestation
at onset of illness (1-45 weeks)
If subject was pregnant at time of illness, did the subject have any adverse outcome to
the pregnancy (e.g. miscarriage, stillbirth, neonatal illness or death) related to the
illness?
For each clinical manifestation reported, indicate (YNU) whether the subject
developed the specified manifestation as a result of the illness.
What antibiotics were prescribed/administered to the patient for treatment of this
illness?
If subject was hospitalized, were any of the following procedures or treatments done?
Were any animals sick at the time of contact?
Specify the sick animal/s the patient had contact with at this location
Did the subject use well water or rainwater collected in cisterns, drums, or other
containers for drinking or bathing?
If the subject used well water or collected rainwater for drinking or bathing, was the
water boiled, chemically treated, or UV treated prior to use?
Flooding Location
Does the patient have any of the following pre-existing medical conditions?
Indicate the state where the subject’s workplace is located
Indicate the city where the subject’s workplace is located
Indicate the zip code where the subject’s workplace is located
Did the subject have any open wounds or cuts in the 30 days prior to illness onset?

If the subject saw rodents in the 30 days prior to illness onset, what type of rodent(s)
were seen?
If the Microscopic Agglutination Test (MAT) was performed, specify the serovar(s) with
the highest titer.
Did the subject have contact with sewage in the 30 days prior to illness onset?
Indicate the types of activity that led to the selected animal, water or mud contact.
Multiple activities can be selected for the type of exposure.
Indicate the county where the selected exposure occurred
Indicate the state where the selected exposure occurred
Indicate the country where the selected exposure occurred
Indicate the specific location where exposure occurred (e.g. home, work, name of
park, name of lake)
Patient Address City
If the patient has an immunosuppressive condition, specify the condition.
Number of days of work or school the patient missed due to this illness?
If the subject had contact with well water, cistern water, or rainwater collected in a
drum or other container, did the well, cistern or other container have a lid?
Where did the subject see rodents or evidence of rodents?

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

CDC Priority (Legacy)

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

N/A
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
N/A
PHVS_YesNoUnknown_CDC
N/A
PHVS_YesNoUnknown_CDC
TBD
Specify the location where flooding occurred
TBD
PHVS_State_FIPS_5-2
N/A
N/A
PHVS_YesNoUnknown_CDC

TBD
N/A
PHVS_YesNoUnknown_CDC
TBD
N/A
PHVS_State_FIPS_5-2
N/A
N/A
N/A
N/A
N/A
PHVS_YesNoUnknown_CDC
TBD

CDC Priority (New)

TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD

TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
2
3
3
3
3

Listeria
Label/Short
Name

Description

Value Set
CDC Priority CDC Priority
Code. Search (Legacy)
(New)
in PHIN VADS
using the
following link
(https://phin
vads.cdc.gov/
vads/SearchH
ome.action)

ID assigned
by database
CdcId
ID assigned
by CDC
ReportStatus Status of
report
FormVersion Version of
form
FoodNetID The FoodNet
ID for the
imported
report (if
applicable)
CaseStateID The State Epi
ID to identify
the report
being
imported.
CaseLocalID The Local Epi
ID to identify
the report
being
imported.
Interviewer The name of
the
interviewer.
Was the
SentLab
isolate sent
to the public
health
laboratory?
SentLabSpeci If isolate not
fy
sent to state
lab, why not
and could it
still be
obtained?
CaseId

Page 275

Listeria
DateComplet The date that
edBy
the form was
completed
on.
Gender
City

Gender
The city of
residence
where the
report/case
originated.
ResidenceCo The county of
unty
residence
where the
report/case
originated.
State of
The state of
Residence
residence
where the
report/case
originated.
Age
Age of casepatient.
DateOfBirth Date of birth
Is the caseEthnicity
patient of
Hispanic,
Latino, or
Spanish
origin?
HispanicMexi Mexican,
can
Mexican
American,
Chicano
HispanicPuer Puerto Rican
toRican
HispanicCuba Cuban
n
HispanicOthe Another
r
Hispanic,
Latino, or
Spanish
Origin
HispanicSpeci If another
fy
Hispanic,
Latino, or
Spanish
origin,
specify.

Page 276

Listeria
HispanicUnkn Unknown
Hispanic
own
ancestry/decl
ined to
specify
RaceAfricanA African
merican_Blac American/Bla
k
ck
RaceAsian
Asian
RaceAsianInd Asian Indian
ian
RaceAsianChi Chinese
nese
RaceAsianFili Filipino
pino
RaceAsianJap Japanese
anese
RaceAsianKor Korean
ean
RaceAsianVie Vietnamese
tnamese
RaceAsianOt Other Asian
her
RaseAsianOt Other Asian,
herSpecify
specify
RaceNativeH Native
awaiian_Oth Hawaiian or
erPacificIslan Other Pacific
der
Islander
RacePacificIsl Native
anderHawaiia Hawaiian
n
RacePacificIsl Guamanian
anderGuama or Chamorro
nian
RacePacificIsl Samoan
anderSomoa
n
RacePacificIsl Other Pacific
anderOther Islander
RaceNativeA Native
merican
American or
Alaska Native
RaceWhite White
RaceWhiteMi Middle
Eastern/Nort
dEast
h African

Page 277

Listeria
RaceWhiteNo Not Middle
Eastern/Nort
tMidEast
h African
RaceUnknow Unknown
n
Race
RaceOther
Other Race
RaceOtherSp Other Race
ecify
Specify
RaceDecline Declined to
answer race
question(s)
Pregnancy
Is Listeria
case
associate
with
pregnancy?
BloodNP
Not
Pregnant:
Type of
specimen
that grew
Listeria. Blood
BloodNPDate Not
Pregnant:
Specimen
collection
date. - Blood
BloodNPIDNu Not
mber
Pregnant:
State public
health lab
isolate ID #. Blood
CSFNP
Not
Pregnant:
Type of
specimen
that grew
Listeria. - CSF
CSFNPDate

Not
Pregnant:
Specimen
collection
date. - CSF

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Listeria
CSFNPIDNum Not
Pregnant:
ber
State public
health lab
isolate ID #. CSF
OtherNP
Not
Pregnant:
Type of
specimen
that grew
Listeria. Other
OtherNPSpec Not
Pregnant:
Specify other
type of
specimen
that grew
Listeria.
OtherNPDate Not
Pregnant:
Specimen
collection
date. - Other
OtherNPIDNu Not
mber
Pregnant:
State public
health lab
isolate ID #. Other
Not
OtherNP2
Pregnant:
Type of
specimen
that grew
Listeria. Other
OtherNP2Spe Not
Pregnant:
c
Specify other
type of
specimen
that grew
Listeria.
OtherNP2Dat Not
Pregnant:
e
Specimen
collection
date. - Other

Page 279

Listeria
OtherNP2IDN Not
Pregnant:
umber
State public
health lab
isolate ID #. Other
NPSpecimenF Not
lag
Pregnant:
Other flag
BacteremiaN Not
P
Pregnant: Did
patient have
any types of
illnesses
related to the
Listeria
infection? Bloodstream
infection/sep
sis
MeningitisNP Not
Pregnant: Did
patient have
any types of
illnesses
related to the
Listeria
infection? Meningitis
NpListeriaIlln Not
essMeningo Pregnant: Did
patient have
any types of
illnesses
related to the
Listeria
infection? Meningoence
phalitis
FebrileGastro Type of
enteritisNP illness-Febrile
gastroenteriti
s, nonpregnant
case

Page 280

Listeria
NpListeriaIlln Not
essBrain
Pregnant: Did
patient have
any types of
illnesses
related to the
Listeria
infection? Brain abscess

NpListeriaIlln Not
essRhomb
Pregnant: Did
patient have
any types of
illnesses
related to the
Listeria
infection? Rhombencep
halitis
NpListeriaIlln Not
essPer
Pregnant: Did
patient have
any types of
illnesses
related to the
Listeria
infection? Peritonitis
NpListeriaIlln Not
essPneu
Pregnant: Did
patient have
any types of
illnesses
related to the
Listeria
infection? Pneumonia

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Listeria
NPListeriaIlln Not
essWound
Pregnant: Did
patient have
any types of
illnesses
related to the
Listeria
infection? Wound
infection
NpListeriaIlln Not
essJoint
Pregnant: Did
patient have
any types of
illnesses
related to the
Listeria
infection? Joint
infection/sep
tic arthritis
NPListeriaIlln Not
essBone
Pregnant: Did
patient have
any types of
illnesses
related to the
Listeria
infection? Bone
infection/ost
eomyelitis
OtherIllnessN Not
P
Pregnant: Did
patient have
any types of
illnesses
related to the
Listeria
infection? Other illness

Page 282

Listeria
OtherIllnessN Not
PSpec
Pregnant: Did
patient have
any types of
illnesses
related to the
Listeria
infection? Other illness
specify
UnknownNP Not
Pregnant: Did
patient have
any types of
illnesses
related to the
Listeria
infection? Unknown
HospitalizedN Not
Pregnant:
P
Was patient
hospitalized
for
listeriosis?
AdmitNP
Not
Pregnant: If
patient
hospitalized
for listeriosis,
admit date.
DischargeNP Not
Pregnant: If
patient
hospitalized
for listeriosis,
discharge
date.

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Listeria
Stillhospitaliz Not
edNP
Pregnant: If
patient
hospitalized
for listeriosis,
still
hospitalized?

NPHospitalize Not
dListeriosisSti Pregnant: If
llDate
patient
hospitalized
for listeriosis,
still
hospitalized
last date.
OutcomeNP Not
Pregnant: Did
the patient
survive?
NPOutcomeD Not
Pregnant: If
ied
the patient
died, what
was the
date?
NPOutcomeLi Not
steriosisDeat Pregnant: If
hCert
died, was
listeriosis or
Listeria
infection
listed on
death
certificate?
NPOutcomeL Not
Pregnant: If
astAlive
survived, last
known date
alive.
BloodMother Pregnant:
Type of
AP
specimen
that grew
Listeria. Blood from
mother

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Listeria
BloodMother Pregnant:
Specimen
APDate
collection
date. -Blood
from mother
BloodMother Pregnant:
APIDNumber State public
health lab
isolate ID #. Blood from
mother
BloodNeonat Pregnant:
eAP
Type of
specimen
that grew
Listeria. Blood from
neonate
BloodNeonat Pregnant:
eAPDate
Specimen
collection
date. - Blood
from neonate
BloodNeonat Pregnant:
eAPIDNumbe State public
health lab
r
isolate ID #. Blood from
neonate
CSFMotherAP Pregnant:
Type of
specimen
that grew
Listeria. - CSF
from mother
CSFMotherAP Pregnant:
Date
Specimen
collection
date. - CSF
from mother
CSFMotherAP Pregnant:
IDNumber
State public
health lab
isolate ID #. CSF from
mother

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Listeria
CSFNeonateA Pregnant:
P
Type of
specimen
that grew
Listeria. - CSF
from neonate
CSFNeonateA Pregnant:
PDate
Specimen
collection
date. - CSF
from neonate
CSFNeonateA Pregnant:
PIDNumber State public
health lab
isolate ID #. CSF from
neonate
PlacentaAP Pregnant:
Type of
specimen
that grew
Listeria. Placenta
PlacentaAPD Pregnant:
Specimen
ate
collection
date. Placenta
PlacentaAPID Pregnant:
Number
State public
health lab
isolate ID #. Placenta
AmnioticAP Pregnant:
Type of
specimen
that grew
Listeria. Amniotic
Fluid
AmnioticAPD Pregnant:
ate
Specimen
collection
date. Amniotic
fluid

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Listeria
AmnioticAPID Pregnant:
State public
Number
health lab
isolate ID #. Amniotic
fluid
PrSpecimenT Pregnant:
ypeFetal
Type of
specimen
that grew
Listeria. Fetal tissue
PrSpecimenC Pregnant:
ollectionFetal Specimen
collection
date. - Fetal
tissue
PrSpecimenIs Pregnant:
olateIDFetal State public
health lab
isolate ID #. Fetal tissue
Pregnant:
OtherAP
Type of
specimen
that grew
Listeria. Other
OtherAPSpec Pregnant:
Specify other
type of
specimen
that grew
Listeria. Other
OtherAPDate Pregnant:
Specimen
collection
date. - Other
OtherAPIDNu Pregnant:
mber
State public
health lab
isolate ID #. Other
Other2AP
Pregnant:
Type of
specimen
that grew
Listeria. Other

Page 287

Listeria
Other2APSpe Pregnant:
Specify other
c
type of
specimen
that grew
Listeria. Other
Other2APDat Pregnant:
Specimen
e
collection
date. -Other
Other2APIDN Pregnant:
umber
State public
health lab
isolate ID #. Other
APSpecimenF Pregnant:
lag
Other flag
OutsideUSSp If born
ecify
outside of
the US,
specify
where.
BornInUS
Denotes that
the <case>
was born
inside the
United
States.
Denotes that
OutsideUS
the <case>
was born
outside the
United
States.
PrimaryLangu Primary
age
language of
the <case>,
either
english,
spanish,
other
(specify) or
unknown.

Page 288

Listeria
PrimaryLangu Specify the
ageSpecify primary
language if it
is not
available in
the original
list.
YearCametoU If born
outside of
S
the US,
specify the
year <case>
arrived.
CDC_EFORSI CDC EFORS ID
D
BloodNPLab Lab
submitting
blood
specimen,
non-pregnant
case
CSFNPLab

Lab
submitting
CSF
specimen,
non-pregnant
case

OtherNP2Lab Lab
submitting
other
specimen 2,
non-pregnant
case
OtherNPLab Lab
submitting
other
specimen,
non-pregnant
case
StoolNP

Stool
specimen
grew Listeria,
non-pregnant
case

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Listeria
StoolNPDate Date stool
specimen
collected,
non-pregnant
case
StoolNPLab

Lab
submitting
stool
specimen,
non-pregnant
case

StoolNPIDNu State public
mber
health isolate
ID number,
stool, nonpregnant
case
BloodMother Lab
APLab
submitting
blood
specimen
from mother,
pregnancyassociated
case
BloodNeonat Lab
eAPLab
submitting
blood
specimen
from
neonate,
pregnancyassociated
case
CSFMotherAP Lab
Lab
submitting
CSF specimen
from mother,
pregnancyassociated
case

Page 290

Listeria
CSFNeonateA Lab
PLab
submitting
CSF specimen
from
neonate,
pregnancyassociated
case
StoolMother Stool
AP
specimen
from mother
grew Listeria,
pregnancyassociated
case
StoolMother Date stool
APDate
specimen
from mother
collected,
pregnancyassociated
case
StoolMother Lab
APLab
submitting
stool
specimen
from mother,
pregnancyassociated
case
StoolMother State public
APIDNumber health isolate
ID number,
stool
specimen
from mother,
pregnancyassociated
case

Page 291

Listeria
PlacentaAPLa Lab
submitting
b
placenta
specimen,
pregnancyassociated
case
AmnioticAPLa Lab
b
submitting
amniotic fluid
specimen,
pregnnacyassociated
case
OtherAPLab Lab
submitting
other
specimen,
pregnancyassociated
case
None
Underlying
conditions
and
treatments. None
Cancer
Underlying
conditions
and
treatments. Cancer
Leukemia
If Cancer,
Leukemia
Lymphoma If Cancer,
Lymphoma
Hodgkins
If Lymphoma,
Hodgkins
NonHodgkins If Lymphoma,
NonHodgkins
MultipleMyel If Cancer,
Multiple
oma
Myeloma

Page 292

Listeria
Myeloprolifer If Cancer,
ative
Myeloprolifer
ative disorder
OtherCancer If Cancer,
Other cancer
OtherCancerS If Other
Cancer,
pecify
specify other
cancer
KidneyDialysi Underlying
conditions
s
and
treatments. Kidney
dialysis
CirrhosisLiver Underlying
Disease
conditions
and
treatments. Cirrhosis/adv
anced liver
disease
COPD

Underlying
conditions
and
treatments. Chronic
Obstructive
Pulmonary
Disease
HeartDisease Underlying
conditions
and
treatments. Heart Disease
HeartDisease If Heart
Specify
Disease,
specify heart
disease
OrganTranspl Underlying
ant
conditions
and
treatments. Organ
transplant

Page 293

Listeria
OrganTranspl If Organ
antSpecify
Transplant,
specify organ
Underlying
conditions
and
treatments. Unknown
OtherConditi Underlying
conditions
ons
and
treatments. Other
conditions
Crohns
Underlying
conditions
and
treatments. Crohn's
Diabetes
Underlying
conditions
and
treatments. Diabetes
mellitus
DiabetesType If Diabetes
mellitus,
I
Type 1
DiabetesType If Diabetes
II
mellitus,
Type 2
GiantCell
Underlying
conditions
and
treatments. Giant cell
arteritis
Hemochroma Underlying
tosis
conditions
and
treatments. Hemochroma
tosis/iron
overload
Unknown

Page 294

Listeria
HIV_AIDS

HIV

Underlying
conditions
and
treatments. HIV/AIDS
If HIV/AIDS,
HIV (no AIDS)

AIDS

If HIV/AIDS,
AIDS
Underlying
Lupus
conditions
and
treatments. Lupus
RheumatoidA Underlying
rthritis
conditions
and
treatments. Rheumatoid
arthritis
Underlying
conditions
and
treatments. Sarcoidosis
SickleCell
Underlying
conditions
and
treatments. Sickle cell
disease
Splenectomy Underlying
conditions
and
treatments. Splenectomy
/asplenia
Sarcoidosis

UlcerativeCol Underlying
itis
conditions
and
treatments. Unlcerative
colitis

Page 295

Listeria
Other1

Other1Spec

Underlying
conditions
and
treatments. Other
condition
If Other
Condition,
specify other
conditions

Cond_Pregna Underlying
ncy
conditions
and
treatments. Pregnancy
Immunosupp Underlying
ressiveMed conditions
and
treatments. Immunosupp
ressive
medication
If
Immunosupp
ressive
medication,
Corticosteroi
ds/steroids
CancerChem If
otherapy
Immunosupp
ressive
medication,
Cancer
chemotherap
y
OtherImmun If
osuppresive Immunosupp
ressive
medication,
Other
immunosupp
ressive
therapy
Steroids

Page 296

Listeria
OtherImmun If Other
Immunosupp
oSpecify
ressive
therapy,
specify
therapy
Alcohol
Underlying
conditions
and
treatments. Excessive
alcohol use
IDU
Underlying
conditions
and
treatments. Injection
drug user
Antacids
Underlying
conditions
and
treatments. Medications
that suppress
stomach acid

AntacidsSpeci If
fy
Medications
that suppress
stomach acid,
specify
medications
InterviewPati Was patient
entAble
or surrogate
able to be
interviewed?
InterviewPati If patient or
surrogate
entReason
was not
interviewed,
why not?

Page 297

Listeria
InterviewPati Other reason
entReasonSp patient or
ecify
surrogate
was not
interviewed.
StomachUlce StomachUlce
rs
rs
Arthritis
Arthritis
KidneyDiseas KidneyDiseas
e
e
StomachSurg StomachSurg
ery
ery
Hypertension Hypertension
ESRD
ESRD
ChronicDiarr ChronicDiarr
hea
hea
Comments Comments
Underlying Underlying
Radiation
Radiation
Antibiotics
Antibiotics
Other2
Other
symptoms
Other3
Name of
store/restaur
ant/other
venue where
soft white
cheese
purchased 3
Other4

Name of
store/restaur
ant/other
venue where
soft white
cheese
purchased 4

Other5

Name of
store/restaur
ant/other
venue where
soft white
cheese
purchased 5

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Listeria
Other 2
specify
Other3Spec Other 3
specify
Other4Spec Other 4
specify
Other5Spec Other 5
specify
PrInfant1Preg Pregnant:
nancyOutco Infant 1
me
pregnancy
outcome.
PrInfant1Ges Pregnant:
tationWeeks Infant 1
weeks of
gestation.
PrInfant1Deli Pregnant:
veryType
Infant 1
delivery type.
Other2Spec

PrInfant1Preg Pregnant:
nancyOutco Infant 1
meDate
pregnancy
outcome
date.
PrInfant1Preg Pregnant:
nancyOutco Specify other
meOtherSpec outcome of
ify
pregnancy
for infant 1?
PrInfant2Preg Pregnant:
nancyOutco Infant 1
pregnancy
me
outcome.
PrInfant2Ges Pregnant:
tationWeeks Infant 1
weeks of
gestation.
PrInfant2Deli Pregnant:
veryType
Infant 1
delivery type.
PrInfant2Preg Pregnant:
nancyOutco Infant 1
pregnancy
meDate
outcome
date.

Page 299

Listeria
PrInfant2Preg Pregnant:
nancyOutco Specify other
meOtherSpec outcome of
ify
pregnancy
for infant 1?
PrMotherIlln Pregnant:
essFever
Type(s) of
illness in
mother.Fever
PrMotherIlln Pregnant:
essBacteremi Type(s) of
a
illness in
mother.Bacteremia/s
epsis
PrMotherIlln Pregnant:
essMeningitis Type(s) of
illness in
mother.Meningitis
PrMotherIlln Pregnant:
essAmnioniti Type(s) of
illness in
s
mother.Amnionitis
PrMotherIlln Pregnant:
essFlu
Type(s) of
illness in
mother.-Nonspecific flulike illness
PrMotherIlln Pregnant:
essNone
Type(s) of
illness in
mother.None
PrMotherIlln Pregnant:
essOther
Type(s) of
illness in
mother.Other
PrMotherIlln Pregnant: If
essOtherSpec Other Illness,
ify
specify

Page 300

Listeria
PrMotherIlnn Pregnant:
essUnknown Type(s) of
illness in
mother.Unknown
PrMotherHos Pregnant:
pLst
Was mother
hospitalized
for
listeriosis?
PrMotherHos Pregnant: If
pListAdmit mother was
hospitalized
for listeriosis,
admit date.
PrMotherHos Pregnant: If
pDischarge mother was
hospitalized
for listeriosis,
discharge
date.
PrMotherHos Pregnant: If
pListStill
mother was
hospitalized
for listeriosis,
still
hopsitalized?

PrMotherHos Pregnant: If
pListHospital mother was
hospitalized
for listeriosis,
name of
hospital.
PrMotherOut Pregnant: Did
comeSurvive the mother
d
survive?
PrMotherOut Pregnant: If
comeLastAliv the mother
survived, last
e
known date
alive.

Page 301

Listeria
PrMotherOut Pregnant: If
comeDeathC the mother
died, was
ert
listeriosis or
Listeria
infection
listed on
death
certificate?
PrInfant1Illne Pregnant:
ssBacteremia Type(s) of
illness in
infant 1.Bacteremia/s
epsis
PrInfant1Illne Pregnant:
ssMeningitis Type(s) of
illness in
infant 1.Meningitis
PrInfant1Illne Pregnant:
ssPneumonia Type(s) of
illness in
infant 1.Pneumonia
PrInfant1Illne Pregnant:
ssNone
Type(s) of
illness in
infant 1.None
PrInfant1Illne Pregnant:
ssOther
Type(s) of
illness in
infant 1.Other
PrInfant1Illne Pregnant:
ssSpecify
Specify other
type(s) of
illness in
infant 1.
PrInfant1Illne Pregnant:
ssUnknown Type(s) of
illness in
infant 1.Unknown
PrInfant1Deli Pregnant:
vered
Where was
infant 1
delivered?

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Listeria
PrInfant1Deli Pregnant: If
veredAdmit infant 1 was
delivered at a
hospitalized,
admit date.
PrInfant1Deli Pregnant: If
veredDischar infant 1 was
ge
delivered at a
hospitalized,
discharge
date.
PrInfant1Deli Pregnant: If
veredStill
infant 1 was
delivered at a
hospitalized,
still
hopsitalized?

PrInfant1Deli Pregnant: If
veredHospita infant 1 was
l
hospitalized
for listeriosis,
name of
hospital.
PrInfant1Out Pregnant:
comeSpecify Specify other
location
where infant
1 was
delivered?
PrInfant1Hos Pregnant:
pList
Was infant 1
hospitalized
for
listeriosis?
PrInfant1Hos Pregnant: If
pListAdmit infant 1 was
hospitalized
for listeriosis,
admit date.

Page 303

Listeria
PrInfant1Hos Pregnant: If
pListDischarg infant 1 was
e
hospitalized
for listeriosis,
discharge
date.
PrInfant1Hos Pregnant: If
pStill
infant 1 was
hospitalized
for listeriosis,
still
hopsitalized?

PrInfant1Out Pregnant: Did
comeSurvive infant 1
d
survive?
PrInfant1Out Pregnant: If
comeLastAliv infant 1
e
survived, last
known date
alive.
PrInfant1Out Pregnant: If
comeDeathC infant 1 died,
ert
was listeriosis
or Listeria
infection
listed on
death
certificate?
PrInfant2Illne Pregnant:
ssBacteremia Type(s) of
illness in
infant 2.Bacteremia/s
epsis
PrInfant2Illne Pregnant:
ssMeningitis Type(s) of
illness in
infant 2.Meningitis
PrInfant2Illne Pregnant:
ssPneumonia Type(s) of
illness in
infant 2.Pneumonia

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Listeria
PrInfant2Illne Pregnant:
Type(s) of
ssNone
illness in
infant 2.None
PrInfant2Illne Pregnant:
ssOther
Type(s) of
illness in
infant 2.Other
PrInfant2Illne Pregnant:
ssSpecify
Specify other
type(s) of
illness in
infant 2.
PrInfant2Illne Pregnant:
ssUnknown Type(s) of
illness in
infant 2.Unknown
PrInfant2Deli Pregnant:
Where was
vered
infant 2
delivered?
PrInfant2Deli Pregnant: If
veredAdmit infant 2 was
delivered at a
hospitalized,
admit date.
PrInfant2Deli Pregnant: If
veredDischar infant 2 was
ge
delivered at a
hospitalized,
discharge
date.
PrInfant2Deli Pregnant: If
veredStill
infant 2 was
delivered at a
hospitalized,
still
hopsitalized?

Page 305

Listeria
PrInfant2Deli Pregnant: If
veredHospita infant 2 was
l
hospitalized
for listeriosis,
name of
hospital.
PrInfant2Out Pregnant:
comeSpecify Specify other
location
where infant
2 was
delivered?
PrInfant2Hos Pregnant:
Was infant 2
pList
hospitalized
for
listeriosis?
PrInfant2Hos Pregnant: If
pListAdmit infant 2 was
hospitalized
for listeriosis,
admit date.
PrInfant2Hos Pregnant: If
pListDischarg infant 2 was
e
hospitalized
for listeriosis,
discharge
date.
PrInfant2Hos Pregnant: If
pListStill
infant 2 was
hospitalized
for listeriosis,
still
hopsitalized?

PrInfant2Out Pregnant: Did
comeSurvive infant 2
d
survive?
PrInfant2Out Pregnant: If
comeLastAliv infant 2
survived, last
e
known date
alive.

Page 306

Listeria
PrInfant2Out Pregnant: If
comeDeathC infant 2 died,
ert
was listeriosis
or Listeria
infection
listed on
death
certificate?
PrMotherIlln Pregnant:
essGastroent Type(s) of
eritis
illness in
mother.Gastroenterit
is
PrInfant1Illne Pregnant:
ssGranuloma Type(s) of
tosis
illness in
infant1.Granulomato
sis
PrInfant2Illne Pregnant:
ssGranuloma Type(s) of
illness in
tosis
infant2.Granulomato
sis
InterviewDat Date of
e
patient
interview.
Interviewee Respondent
of the patient
interview.
Relationship If respondent
was
surrogate,
relationship
to patient.
OtherRelatio If respondent
nshipSpecify was
surrogate,
relationship
to patient
specify other.

Onset

Date illness
began.

Page 307

Listeria
IllnessBeginN Date illness
otApplicable began does
not apply.
HospitalizedB During the 4
efore
weeks before
illness/delive
ry date, was
admitted to a
hospital?

HAdmit

If admitted to
a hospital,
admission
date.

HDischarge

If admitted to
a hospital,
discharge
date.

Hname

If admitted to
a hospital,
hospital
name.

StillHosp

If admitted to
a hospital,
still residing
there?

NursingHome During the 4
Before
weeks before
illness/delive
ry date, was
admitted to a
nursing
home?

Admitdate

Date
admitted to
nursing home
(if resident in
4 weeks prior
to onset)

Page 308

Listeria
DischargeDat Dicharge
e
date from
nursing home
(if resident in
4 weeks prior
to onset)
StillHosporN If admitted to
a nursing
H
home, still
residing
there?
NHName
If admitted to
a nursing
home,
nursing home
name.
TravelState

Page 309

Label/Short Name
TB State Case Number
City or County Case Number
Birth Sex
Previously Counted Case
Previously Reported State Case Number
Country of Verified Case
Patient Address City
Inside City Limits
Census Tract of Case-Patient Residence

Detailed Race
Date Arrived in US
US Born
Primary Guardian(s) Country of Birth
Remain in US After Report
Initial Reason for Evaluation
Test Type

Test Result

Date/Time of Lab Result
Specimen Source Site
Specimen Collection Date/Time

Test Result Quantitative

Result Units
Type of Chest Study

Result of Chest Study
Evidence of Cavity
Evidence of Miliary TB
Date of Chest Study
Current Occupation
Current Occupation Standardized

Current Industry
Current Industry Standardized

Patient Epidemiological Risk Factors
Patient Epidemiological Risk Factors
Indicator
Type of Correctional Facility
Type of Long-Term Care Facility
Smoking Status
Patient lived outside of US for more
than 2 months
Identified During Contact Investigation
Evaluation During Contact Investigation

Linked Case Number
Date Treatment or Therapy Started
Treatment Administration Type
Date Treatment or Therapy Stopped
Treatment Started
Initial LTBI Drug Regimen
Primary Reason LTBI Treatment Not
Started
Reason LTBI Treatment Stopped
NTSS State Case Number
Adverse Event Severity
Usual Occupation and Industry
Meets Binational Reporting Criteria

Description
State case number for the case specific to TB investigations (4 digit report
year + 2 letter state + 9 digit alphanumeric number)
City or county case number assigned to this case
What was the patient's sex at birth?
Has this case already been counted by another reporting area?

Value Set Code. Search in
PHIN VADS using the
following link
(https://phinvads.cdc.gov/v
ads/SearchHome.action)
N/A
N/A
PHVS_Sex_MFU
PHVS_CaseCountStatus_TB

If case previously counted, provide the state case number from the other
reporting area.
If the case was previously reported by another country, specify the country.

N/A

Patient address city
Is the patient's residence within city limits?

N/A
PHVS_YesNoUnknown_CDC

PHVS_BirthCountry_CDC

Census tract where the address is located is a unique identifier associated
N/A
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.
Provide the detailed race information for the patient.
PHVS_Race_CDC
If country of birth is NOT United States, regardless of citizenship, indicate the N/A
date when the patient first arrived in the US.
Was the patient eligible for US citizenship at birth?
PHVS_YesNoUnknown_CDC
Indicates the birth country of the primary guardian(s) of patient (pediatric
[<15 years old] cases only)
If not US reporting area, did patient remain in the United States for >= 90
days after report date?
What was the initial reason the patient was evaluated for TB?
Epidemiologic interpretation of the type of test(s) performed for this case.
Please provide a response for each of the main test types (culture, smear,
pathology/cytology, NAA, TST, IGRA, HIV, diabetes) If test was not done
please indicate so.
Epidemiologic interpretation of the results of the test(s) performed for this
case - This is a qualitative test result. (e.g., positive, detected, negative)
Date result sent from reporting laboratory. Time of result is an optional
addition to date.
This indicates the anatomical source of the specimen tested.
Date of collection of laboratory specimen used for diagnosis of health event
reported in this case report. Time of collection is an optional addition to date.
Quantitative test result value

PHVS_BirthCountry_CDC
PHVS_YesNoUnknown_CDC
PHVS_PrimaryReasonForEva
luation_TB
PHVS_LabTestType_TB

PHVS_LabTestInterpretation
_TB
N/A
PHVS_MicroscopicExamCult
ureSite_TB
N/A

N/A

Units of measure for the Quantitative Test Result Value
PHVS_UnitofMeasure_TB
Indicate the type of chest study performed. Please provide a response for
PHVS_TypeofRadiologyStud
each of the main test types (plain chest radiograph, chest CT Scan) and if test y_CDC
was not done please indicate so.
Result of chest diagnostic testing
PHVS_ResultofRadiologyStu
dy_TB
Did test show evidence of cavity?
PHVS_YesNoUnknown_CDC
Did test show evidence of miliary TB?

PHVS_YesNoUnknown_CDC

Date of the chest diagnostic study
This data element is used to capture the narrative text of a subject's current
occupation.
This data element is used to capture the CDC NIOSH standard occupation
code based upon the narrative text of a subject's current occupation.

N/A
N/A
PHVS_Occupation_CDC_Cen
sus2010

(The National Institute for Occupational Safety and Health (NIOSH) has
developed a web-based software tool designed to translate industry and
occupation text to standardized Industry and Occupation codes. The NIOSH
Industry and Occupational Computerized Coding System (NIOCCS) is available
here: http://www.cdc.gov/niosh/topics/coding/overview.html
This data element is used to capture the narrative text of subject's current
industry.
This data element is used to capture the CDC NIOSH standard industry code
based upon the narrative text of a subject's current industry.

N/A
PHVS_Industry_CDC_Census
2010

(The National Institute for Occupational Safety and Health (NIOSH) has
developed a web-based software tool designed to translate industry and
occupation text to standardized Industry and Occupation codes. The NIOSH
Industry and Occupational Computerized Coding System (NIOCCS) is available
here: http://www.cdc.gov/niosh/topics/coding/overview.html
Exposed risk factors for the patient - Please provide a response for all risk
factors in the value set with an associated indicator
Provide a response for each value in the patient epidemiological risk factors
value set
If patient was a Resident of Correctional Facility at Diagnostic Evaluation,
indicate the type of correctional facility.
If patient was a Resident of Long Term Care Facility at Diagnostic Evaluation,
indicate the type of long term care facility.
What is the patient's current tobacco smoking status?
Residence or Travel in countries other than the United States, Canada,
Australia, New Zealand, or countries in northern or western Europe for >60
consecutive days at any point in the patient's lifetime.
Was the patient identified during the contact investigation around the likely
source case?
If patient was identified during contact investigation, was the patient
evaluated for TB during the contact investigation?

PHVS_EpidemiologicalRiskFa
ctors_TB
PHVS_YesNoUnknown_CDC
PHVS_CorrectionalFacilityTy
pe_NND
PHVS_LongTermCareFacility
Type_NND
PHVS_SmokingStatus_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

State case numbers for epidemiologically linked cases
Date the initial treatment regimen was started
Choose all treatment administration types that apply to the case, such as
DOT, eDOT, or SAT.
Date treatment stopped
Was treatment started for LTBI?

N/A
N/A
PHVS_TreatmentAdministra
tionType_TB
N/A
PHVS_YesNoUnknown_CDC

If treatment was started indicate the initial LTBI drug regimen.

PHVS_LTBIDrugRegimen_TB

If treatment was not started, what was the primary reason LTBI treatment
was not started?
Reason LTBI treatment stopped

PHVS_ReasonLTBINotStarte
d_TB
PHVS_ReasonLTBITreatment
Stopped_TB
If patient developed TB from LTBI, list the NTSS state case number
N/A
If treatment was stopped due to adverse event from LTBI treatment indicate PHVS_AdverseEventSeverity
the severity.
_TB
Usual occupation and industry
TBD
Does case meet binational reporting criteria?
PHVS_YesNoUnknown_CDC

CDC Priority
P
P
P
P
P
P
P
P
P

P
P
P
P
P
P
P

P

P
P
P

P

P
P

P
P
P
P
P
P

P
P

P
P
P
P
P
P

P
P

P
P
P
P
P
P
P
P
P
P
P
P

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
Exposure in high incidence state
Symptom onset greater than 30 days
Clinical Manifestation
Clinical Manifestation Indicator
Medication Administered
Date Treatment or Therapy Started
Treatment Duration

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
Did patient live in or visit a state defined as high incidence within 30 days prior to
onset of symptoms?
Did onset of symptoms occur more than 30 days prior to diagnosis?
Clinical manifestation of Lyme disease
For each clinical manifestation reported, indicate whether the subject developed the
specified manifestation as a result of the illness.
What antibiotic did the patient receive for this episode?
Date the treatment or therapy was initiated
Number of days the patient actually took the antibiotic referenced

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
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_ClinicalManifestations_Lyme
PHVS_YesNoUnknown_CDC
PHVS_MedicationReceived_Lyme
N/A
N/A

CDC Priority

P
P
P
P
P
P
P

Malaria
Label/Short
Name

Description

Subject's
height
Height Units Subject's
height units
Subject's
Weight
weight
Weight Units Subject's
weight units

Value Set
CDC Priority
Code. Search
in PHIN VADS
using the
following link
(https://phin
vads.cdc.gov/
vads/SearchH
ome.action)

Height

Hospital
Name

PHVS_Height
Unit_UCUM

PHVS_Weight
Unit_UCUM

Name of
free text
hospital
where case
was admitted

Hospital
Record
Number, if
subject was
hospitalized
Patient last Patient's last free text
name
name
Patient first Patient's first free text
name
name
Physician last Last name of free text
name
physician
seen for this
case
Physician first First name of free text
name
physician
seen for this
case
Physician
Phone
phone
number of
number
the physician
seen for this
case
Hospital
Record
Number

Page 323

Malaria
Reporting
Laboratory
Name
Laboratory Reporting
Phone
Laboratory
Number
Phone
Number
Specimen(s) Was
PHVS_YesNo
sent to CDC? specimen
Unknown_CD
sent to CDC C
for Malaria
confirmation
?
Specimen
Type(s) of
PHVS_Specim
Type(s) sent specimen
enType_Mala
to CDC
sent to CDC. ria
Description Description free text
of other
of the other
specimen
type of
type
specimen
sent to CDC
Epidemiologi PHVS_LabTes
Test Type
c
tProcedure_
interpretatio Malaria
n of the type
of test(s)
performed
for this case.
Species
Organism
PHVS_Specie
identified
Name
s_Malaria
through
testing.
Description Description free text
of the other
of other
organism
organism
tested
positive for
Parasitemia The
Level
estimated
Percentage number of
infected
erythrocytes
expressed as
a percentage
of the total
erythrocytes.
Laboratory
Name

Page 324

Malaria
Has the
Subject
PHVS_YesNo
Traveled or subject
Unknown_CD
Lived Outside traveled or C
lived outside
U.S.
the U.S.
during the
past two
years?
Subject
PHVS_YesNo
Did the
Reside in U.S. subject
Unknown_CD
prior to most reside in the C
recent travel U.S. prior to
most recent
travel?
Subject's
If the subject PHVS_Countr
Country of
did not reside y_ISO_3166Residence
in the U.S.
1
prior to most prior to most
recent travel recent travel,
what was the
country of
residence?

Principal
reason for
Travel

If the subject PHVS_Travel
did not reside Reason_Mala
in the U.S.
ria
prior to most
recent travel,
what was the
country of
residence?

Description
of other
reason for
travel

Description free text
of the other
reason for
travel
from/to the
US
International Destination(s PHVS_Countr
Destination(s ) or
y_ISO_3166) or
residence(s) 1
residence(s) outside the
#1
U.S. during
the past 2
years

Page 325

Malaria
Date of
return from
travel #1

Date the
subject
returned/arri
ved to the
U.S. from an
international
destination
or residence.

Duration of
Stay #1

Duration of
stay in
country
outside the
U.S.
Duration of Duration of PHVS_AgeUni
Stay Units #1 stay units in t_UCUM
country
outside the
U.S.
International Destination(s PHVS_Countr
Destination(s ) or
y_ISO_3166residence(s) 1
) or
residence(s) outside the
U.S. during
#2
the past 2
years
Date of
Date the
return from subject
travel #2
returned/arri
ved to the
U.S. from an
international
destination
or residence.

Page 326

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
Age at Rash Onset
Age Type at rash Onset
Chest x-ray for pneumonia
Case Patient a Healthcare Worker
Import Status
Vaccination Doses Prior to Illness
Onset
Date of Last Dose Prior to Illness
Onset
Vaccine History Comments

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
Age of patient at rash onset
Age units of patient at rash onset
Was a chest x-ray for pneumonia done?
Was the case patient a healthcare provider (HCP) at illness onset?
Was this case imported?
Number of vaccine doses against this disease prior to illness onset
Date of last vaccine dose against this disease prior to illness onset
Comments about the subject's vaccination history

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?
State or Local Public Health
Laboratory/LRN POC- Name
State or Local Public Health
Laboratory/LRN POC- Phone number

State or Local Public Health Lab/LRN
POC Email Address
State or Local Public Health Lab/LRN
POC- Affiliation
Case origin/type
Country of travel destination
International Region
Dates of International Travel
Contact with soil or water in
International travel destination
Specific location of exposure for
International Travel
Other close contacts with same
soil/water exposures (International
Travel)
Number of close contacts
(International Travel)
Relationship (International Travel)
Significant weather or environmental
events during this visit (International
Travel)
Specific weather or environmental
events (International Travel)
Contact with soil or water in
melioidosis-endemic areas
Contact with soil or water in
melioidosis-endemic areas service
Date
Travel within U.S. but >50 miles from
residence
State
City/town
Dates of Travel
Contact with soil or water in travel
destination
Specific location of exposure
Other close contacts with same
soil/water exposures
Number of close contacts
Relationship
Significant weather or environmental
events during this visit
Specific weather or environmental
events
Travel (in the last 10 years)

Country of travel destination (in the
last 10 years)
Region of travel in last 10 years
Dates of Travel (in the last 10 years)
Contact with soil or water in travel
destination (in the last 10 years)
Specific location of exposure (in the
last 10 years)
Other close contacts with same
soil/water exposures (International
Travel)
Number of close contacts
(International Travel)
Relationship (International Travel)
Significant weather or environmental
events during this visit (International
Travel)
Specific weather or environmental
events (International Travel)
Specify other or abscess for
"specimen source"
Date of LRN confirmation, if
applicable
AST Request
Dates of Hospitalization
Pneumonia/pleural effusion
Skin/soft tissue infections
Genitourinary infection
Neurologic infection
Pericardial effusion
Bone or joint infection
Internal abscesses
Select or specify location of
abscesses
Additional notes describing
abscesses
Septic Shock
Bacteremia
Date antimicrobial Treatment ended
Liver disease
Excess alcohol abuse
Chronic granulomatous disease
Malignancy
Systemic lupus erythematous
Prior splenectomy
Immunosuppressing drugs

Other immunocompromising
condition
Patient's Occupation
Recreational Gardener
Is this case part of a cluster?
Exposure to Iguanas
Type of Iguana
Type of exposure
If owned, how acquired
Location of purchase or where
acquired
Exposure to Pet Fish
Type of pet fish
Type of exposure
If owned, how acquired
Location of purchase or where
acquired
Exposure to Aquatic Plants
Type of aquatic plant
Type of exposure
If owned, how acquired
Location of purchase or where
acquired
Exposure to Other Animals
Type of "Other Animal"
Type of exposure
If owned, how acquired
Location of purchase or where
acquired
Laboratory exposures identified
Name of Facility (Exposures)
City/town (Exposures)
State (Exposures)
Number of laboratorians exposed
High Risk
Low Risk
Minimal Risk
Date of Exposure
Risk Factors
Laboratory Activity
Risk Category
Serologic Monitoring
Received post-exposure prophylaxis

Reported Symptoms (lab exposures)
Onset Date (lab exposure)
Describe Symptoms

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?
Name of the laboratory person who is the lab POC for this investigation
Phone number of the laboratory person who is the lab POC for this investigation

Email address of person who is reporting cases to CDC
Affiliated Facility of the state LRN/lab POC
Is this a human or animal case?
Choose a country for each destination
Enter region (list multiple if applicable)
Enter dates of travel (multiple if applicable)
Was the subject contact with soil or water during this visit?
If yes to Question above, indicate specific location of exposure
If yes to Question above, indicate whether other close contacts also had the same
soil/water exposure
If yes to Question above, list the total number of close contacts
If yes to Question above, select relationship to subject (select all that apply)
Were there any significant weather or environmental events during this visit?

If yes to Question above, select all weather/environmental events
Has subject ever been in contact with soil or water in melioidosis-endemic areas?
If yes, date of contact in YYYYMM format.

Did the subject travel 50 miles or more outside his or her normal residence but within
the U.S. 30 days prior to onset?
Choose a state each destination
Please indicate city/town (list multiple if applicable)
Enter dates of travel
Was the subject contact with soil or water during this visits?
If yes to Question above, indicate specific location of exposure
If yes to Question above, were there other close contacts also had the same soil/water
exposure
If yes to Question above, list the total number of close contacts
If yes to Question above, select relationship to subject (select all that apply)
Were there any significant weather or environmental events during this visit?

If yes to Question above, select all weather/environmental events
In the 10 years before symptoms onset, did the patient travel outside of the
continental U.S. or to an area in the U.S. where the endemicity is possible

Choose a country for each destination
Enter region (list multiple if applicable)
Enter dates of travel
Was the subject contact with soil or water during this visit?
If yes to Question above, indicate specific location of exposure
If yes to Question above, indicate whether other close contacts also had the same
soil/water exposure
If yes to Question above list the total number of close contacts
If yes to Question above, select relationship to subject (select all that apply)
Were there any significant weather or environmental events during this visit?

If yes to Question above, select all weather/environmental events
If abscess or other specimen selected, please specify
Enter Date of Confirmation by LRN
Is the jurisdiction requesting AST on the isolate
Give reporting jurisdiction ability to enter multiple hospitalizations if needed
Did the subject have pneumonia/pleural effusion
Did the subject have skin/soft tissue infection
Did the subject have genitourinary infection
Did the subject have neurologic infection
Did the subject have pericardial effusion
Did the subject have bone/joint infection
Did the patient have internal abscesses
If yes, for internal abscesses, please select all that apply
If yes for internal abscesses, additional notes (number, location of abscesses)
Did the subject have septic shock
Did the subject have bacteremia
Indicate the date antimicrobial treatment ended
Does subject have liver disease
Does subject have history chronic alcohol abuse?
Does the subject have chronic granulomatous disease?
Does the subject have malignancy?
Does the subject have systemic lupus erythematous?
Does the subject have a history of prior splenectomy
Is the subject on any immunosuppressing medication

Does the patient have any other immunocompromising conditions
What is the patient's occupation
Is the patient a recreational gardener?
Is this case part of a cluster?
In the 30 days prior to symptoms onset did the patient own or have direct contact with
an iguana?
Indicate type of iguana if yes to previous question
Indicate type of exposure if yes to exposure to iguana
If owned an iguana, indicate how case patient acquired
Location of purchase/where acquired (name of river, lake, park, or location of pet store, for
example)

In the 30 days prior to symptoms onset did the patient own or have direct contact with
pet fish?
Indicate type of pet fish if yes to previous question
Indicate type of exposure if yes to exposure to pet fish
If owned a pet fish, indicate how case patient acquired
Location of purchase/where acquired (name of river, lake, park, or location of pet store, for
example)

In the 30 days prior to symptoms onset did the patient own or have direct contact with
aquatic plants?
Indicate type of aquatic plant if yes to previous question
Indicate type of exposure if yes to exposure to aquatic plants
If owned aquatic plant, indicate how case patient acquired
Location of purchase/where acquired (name of river, lake, park, or location of pet store, for
example)

In the 30 days prior to symptoms onset did the patient own or have direct contact with
other animals
Indicate type of other animal if yes to previous question
Indicate type of exposure if yes to exposure to "other animal"
If owned "other animal", indicate how case patient acquired
Location of purchase/where acquired (name of river, lake, park, or location of pet store, for
example)

Were potential laboratory exposures identified in this investigation
Name of facility/hospital where exposures were identified
City of facility where exposures were identified
State where the facility where the exposures were identified
Total number of laboratory personnel exposures
Number of laboratory personnel with high-risk exposures
Number of laboratory personnel with low-risk exposures
Number of laboratory personnel with minimal exposures
For each laboratory personnel, date of exposures
Does the laboratory personnel have risk factors for melioidosis
Select activity that resulted in exposure
For each laboratory personnel and each activity, select risk category
Did the laboratory personnel undergo serologic monitoring
Did the laboratory personnel receive post-exposure prophylaxis

Did the laboratory personnel report symptoms within 21 days of exposure
If the laboratory personnel reported symptoms, please provide onset date
If the laboratory personnel reported symptoms, describe

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

CDC Priority (Legacy)

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
N/A
N/A

N/A
N/A
TBD
PHVS_Country_ISO_3166-1
N/A
N/A
PHVS_YesNoUnknown_CDC
N/A

PHVS_YesNoUnknown_CDC
N/A
TBD

PHVS_YesNoUnknown_CDC
TBD
PHVS_YesNoUnknown_CDC
N/A

PHVS_YesNoUnknown_CDC
PHVS_State_FIPS_5-2
N/A
N/A
PHVS_YesNoUnknown_CDC
N/A
PHVS_YesNoUnknown_CDC
N/A
TBD
PHVS_YesNoUnknown_CDC
TBD

PHVS_YesNoUnknown_CDC

N/A
N/A
N/A

PHVS_YesNoUnknown_CDC
N/A
PHVS_YesNoUnknown_CDC

N/A
TBD
PHVS_YesNoUnknown_CDC

TBD
N/A
N/A
TBD
N/A
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
TBD
N/A
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
N/A
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

PHVS_YesNoUnknown_CDC
N/A
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
N/A
TBD
TBD
N/A
PHVS_YesNoUnknown_CDC
N/A
TBD
TBD
N/A
PHVS_YesNoUnknown_CDC
N/A
TBD
TBD
N/A
PHVS_YesNoUnknown_CDC
N/A
TBD
TBD
N/A
PHVS_YesNoUnknown_CDC
N/A
N/A
PHVS_State_FIPS_5-2
N/A
N/A
N/A
N/A
N/A
TBD
TBD
TBD
TBD
TBD

TBD
N/A
N/A

CDC Priority (New)

1
1

1
1
1
2
3
2
2
3
3

3
3
2

3
2
2

2
2
3
2
2
3
3
3
3
2

3
2

2
2
2
2
3
3

3
3
2

2
2
3
3
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2

2
2
2
3
2
2
2
2
2

2
2
2
2
2

2
2
2
2
2

2
2
2
2
2

1
2
2
2
1
2
2
2
2
2
2
2
2
2

2
2
2

Label/Short Name

Description

MIS ID
Health Department ID
NCOV ID
Abstractor name

Multisystem inflammatory syndrome identifier.
Health Department identifier.
COVID-19 identifier (if available)
Name of person compiling medical records and/or interviews.
Date of abstraction
Fever >38.0°C for ≥24 hours, or report of subjective fever lasting
≥24 hours
Laboratory markers of inflammation (including, but not limited
to one or more; an elevated C-reactive protein (CRP),
erythrocyte sedimentation rate (ESR), fibrinogen, procalcitonin,
d-dimer, ferritin, lactic acid dehydrogenase (LDH), or interleukin
6 (IL-6), elevated neutrophils, reduced lymphocytes and low
albumin),
Evidence of clinically severe illness requiring hospitalization, with
multisystem (>2) organ involvement.
Indicator for associated sign and symptom

Date of abstraction

Temperature if fever
Inflammation laboratory
markers

Signs and symptoms
Signs and symptoms
indicator
No alternative plausible
diagnosis
SARS-COV-2 test
Symptom onset within 4
weeks of exposure
Date of symptom onset
Height
Weight
Body Mass Index
Patient Epidemiological
Risk Factors
Patient Epidemiological
Risk Factors Indicator
Type of complication

Type of complication
indicator

Is there no alternative plausible diagnosis?
Positive for current or recent SARS-COV-2 infection (select all
applicable tests)
COVID-19 exposure within the 4 weeks prior to the onset of
symptoms
If yes, date of first exposure within the 4 weeks prior
Height specified in inches
Weight in pounds
Body Mass Index
Underlying medical conditions or risk behaviors for the case
patient.
Provide a response for each value in the risk factors value set.
Complications associated with the illness being reported
Provide a response for each complication.

If admitted to the ICU, ICU admission date
Days in ICU
Number of days in ICU
Patient outcome
Patient outcome
Did the patient have preceding COVID-like illness?
Preceding COVID-like
illness
Date of onset of preceding If yes, date of onset of preceding illness
COVID-like illness
ICU Admission Date

Fever

Fever ≥ 38.0°C

Date of fever onset
Highest temperature
Number of days febrile
Clinical finding
Clinical finding indicator
Treatment Type
Treatment type indicator
Vasoactive medications
Immune modulators
Antiplatelets
Anticoagulation
Echocardiogram
Max coronary artery Zscore
Cardiac dysfunction
Mitral regurgitation
Date of coronary artery
aneurysm
Abdominal imaging type
Chest imaging type
MIS Inclusion
MIS Inclusion Criteria
MIS Inclusion Criteria
indicator
Patient outcome date
Medical history

Date of fever onset
Highest temperature ©
Number of days febrile
Clinical finding
Provide a response for each clinical finding.
Listing of treatment or medical intervention the subject received
for this illness
Provide a response for each treatment type.
Specify vasoactive medications
Specify immune modulators treatment
Specify antiplatelets treatment
Specify anticoagulation treatment
Select any echocardiogram that apply.
If coronary artery aneurysms, state max coronary artery Z-score.
If cardiac ventricular dysfunction, specify type.
Specify type of mitral regurgitation.
Date of first test showing coronary artery aneurysm or dilatation.
Type of abdominal imaging (ultrasound, CT)
Type of chest imaging (chest x-ray, CT)
Did the patient meet all inclusion criteria associated with MIS
illness case definition
Inclusion criteria associated with the illness being reported
Indicator for associated inclusion criteria

Date of hospital discharge or death
Does the patient have a history of the following illnesses prior
to developing MIS-C symptoms?
Medical history indicator Indicator for associated medical history diagnosis
Date of medical history
Date of past medical history diagnosis
Imaging Study
Listing of imaging studies the subject received for this illness
Imaging Study indicator Provide a response for normal or abnormal results for each
imaging study received
Left ventricular ejection Specify left ventricular ejection fraction (LVEF)
fraction (LVEF) level

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

N/A
N/A
N/A
N/A
N/A
N/A
TBD

TBD

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

TBD
PHVS_YesNoUnknown_CDC
N/A
N/A
N/A
N/A
TBD
PHVS_YesNoUnknown_CDC
TBD
PHVS_YesNoUnknown_CDC
N/A
N/A
TBD
PHVS_YesNoUnknown_CDC

N/A
PHVS_YesNoUnknown_CDC

N/A
N/A
N/A
TBD
PHVS_YesNoUnknown_CDC
TBD
PHVS_YesNoUnknown_CDC
TBD
TBD
TBD
TBD
TBD
N/A
TBD
TBD
N/A
TBD
TBD
PHVS_YesNoUnknown_CDC
MIS Inclusion (MIS)
PHVS_YesNoUnknown_CDC
N/A
Patient history (MIS)
Patient history (MIS)
N/A
Imaging Studies
Normal, Abnormal, Not Done
1:≥55%, 2: 50-54% 3: <50%

CDC Priority (New)

1
1
1
1
1
1
1

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

1

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

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
Bacterial Infection Syndrome
Gestational Age
Birth Weight
Birth Weight Units
Secondary Case
Recurrent Disease with Same
Pathogen

Previous State ID (Recurrent Case)
Case Report Form Status
Had Sex with a Male within the Past
12 Months
Had Sex with a Female within the
Past 12 Months
Number of Male Sexual Partners
HIV Status
Homeless
Signs and Symptoms
Signs and Symptoms Indicator
Eculizumab
Illness Onset Age
Illness Onset Age Units
Residence
Epi-Linked to a LaboratoryConfirmed Case
ABCS Case
ABCS State ID
Laboratory Testing Performed
Laboratory Confirmed
Serogroup Method
Test Manufacturer
Lab Accession Number
Susceptibility Test

Did the Subject Ever Receive a
Vaccine Against This Disease
Date of Last Dose Prior to Illness
Onset
Vaccination Doses Prior to Onset
Vaccine History Comments
Vaccine Name
Age at Vaccination
Age at Vaccination Units
Vaccine History Information Source
Vaccine Information Source
Indicator

Ravulizumab

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.
Types of infection caused by organism
If patient <1 month of age, indicate gestational age (in weeks)
If patient <1 month of age, indicate birth weight (grams)
Birth Weight Units
Is this a secondary case?
Does this case have recurrent disease with the same pathogen? (For Streptococcus
pneumoniae, the specimen from the current case must have been isolated 8 or more
days after any previous case due to the same pathogen. For all other pathogens, the
specimen from the current case must have been isolated 30 or more days after any
previous case due to the same pathogen.)
StateID of 1st occurrence for this pathogen and person.
Case Report Form Status
Had sex with a male within the past 12 months?
Had sex with a female within the past 12 months?
In the 3 months prior to the onset of symptoms, number of male sex partners the
person had?
Documented or self-reported HIV status at the time of event
Was the patient homeless at time of symptom onset?
Indicate what symptoms of interest the patient had during the course of the illness
Indicator for associated sign and symptom
Was the patient taking eculizumab/Soliris at the time of disease onset?
Illness onset age
Illness onset age units
Where was the patient a resident at time of initial culture?
Is this case epi-linked to a laboratory-confirmed case?
ABCs Case?
ABCS State ID
Was laboratory testing done to confirm the diagnosis?
Was the case laboratory confirmed?
Serogroup method
Test Manufacturer
Lab Accession Number (including CDC Lab ID)
Was any susceptibility data available?

Did the subject ever receive a vaccine against this disease?
Date of last vaccine dose against this disease prior to illness onset
Number of vaccine doses against this disease prior to illness onset
Vaccine History Comments
Vaccine Name
The persons age at the time the vaccine was given
The age units of the person at the time the vaccine was given
What sources were used for vaccination history?
Vaccination History Information Source Indicator
Was the patient taking Ravulizumab (Ultomiris) at the time of disease onset?

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

CDC Priority (Legacy)

TBD
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
TBD

PHVS_InfectionType_RIBD
N/A
N/A
PHVS_WeightUnit_UCUM
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

P
P
P
P
P
P

N/A
PHVS_FormStatus_RIBD
PHVS_YNRD_CDC

P
P
P

PHVS_YNRD_CDC

P

N/A

P

PHVS_HIVStatus_STD
PHVS_YesNoUnknown_CDC
PHVS_SignsSymptoms_RIBD

P
P
P

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
N/A
PHVS_AgeUnit_UCUM
PHVS_ResidenceLocation_RIBD
PHVS_YesNoUnknown_CDC

P
P
P
P
P
P

PHVS_YesNoUnknown_CDC
N/A
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_SerogroupMethod_RIBD
N/A
N/A
PHVS_YesNoUnknown_CDC

P
P
P
P
P
P
P
P

PHVS_YesNoUnknown_CDC

P

N/A

P

N/A
N/A
N/A
N/A
PHVS_AgeUnit_UCUM
PHVS_InformationSource_RIBD
PHVS_YesNoUnknown_CDC

P
P
P
P
P
P
P

https://phinvads.cdc.gov/vads/ViewValueSet.action?
oid=2.16.840.1.114222.4.11.888

CDC Priority (New)

3

Label/Short Name

COVID-19 ID
Interviewer Last Name
Interviewer First Name
Interviewer Organization

Description

ID to link all case information on
patient
Last name of interviewer
First name of interviewer
The affiliation or organization of
the interviewer.

Interviewer Telephone

Telephone number of interviewer

Interviewer Email

Email of interviewer
If probable case classification
status, provide reason for
classification.
Under what process was the case
first identified?
If EpiX notification of traveler,
provide the DGMQID.
Date of first positive specimen
collection.
If hospitalized, was a translator
required?
If translator required in the
hospital, specify which language?
Was patient admitted to an
intensive care unit (ICU)?
If patient was admitted to an ICU,
provide the admission date.
If patient was admitted to an ICU,
provide the discharge date.
Select the best description of
where the patient lived at the time
of illness onset.
Is the patient a health care worker
in the U.S.?
If patient is a health care worker,
select their occupation. If other,
specify in text.
If patient is a health care worker,
select their job setting. If other,
specify in text.
In the 14 days prior to illness onset,
did the patient have any of the
following exposures? Select all that
apply.

Probable Classification Reason
Process for Case Identification
DGMQID
Positive Collection Date
Hospital Translator
Translator Language
Intensive Care Unit Admittance
ICU Admission Date
ICU Discharge Date
Housing Type
Health Care Worker
Health Care Worker Job Type

Health Care Worker Job Setting

Exposure of Interest

State of Travel Exposure
Country of Travel Exposure
Cruise Ship or Vessel

Workplace Critical Infrastructure

Workplace Exposure

Animal Case

Type of Contact with COVID-19 Case
Contact with U.S. COVID-19 Case
COVID-19 Case Identifier

If domestic travel outside of state
of normal residence, specify the
state.
If patient traveled internationally,
specify country.
If exposed on a cruise ship or
vessel, specify the name of the
cruise ship.
If the patient was exposed at their
workplace, is the workplace critical
infrastructure?
If workplace exposure, specify the
workplace setting (e.g., long term
healthcare setting, hospital,
grocery store)
If an animal with confirmed or
suspected COVID-19, specify the
animal.
If the patient had contact with a
known COVID-19 case, specify the
type of contact.
Was this person a U.S. case?
If patient had contact with a known
COVID-19 case, specify the COVID19 ID(s).

Select which mechanisms were
used for the collection of the
Clinical History Collection Mechanism
clinical course, symptoms, past
medical history and social history.
Symptomatic
Symptoms Resolved
Clinical Symptoms
Clinical Symptoms Indicator
Diagnostic
Diagnostic Result
Treatment
Treatment Indicator
Days of Mechanical Ventilation

Symptoms present during course
of illness.
Did the patient’s symptoms
resolve?
Indicate the symptoms associated
with this illness.
Indicator for each symptom.
Select the diagnostic tests that
were performed.
Indicator for each diagnostic test
result.
Indicate the treatment received.
Indicator for each treatment.
If patient received mechanical
ventilation intubation, specify the
total days of treatment.

Underlying Risk Factors
Underlying Risk Factors Indicator
Chronic Disease
Underlying Condition
Risk Behavior

Disability

Psychological or Psychiatric Condition
Tribe Affiliation
Tribe Name
Tribe Enrolled Member

Specify any of the underlying
medical conditions and/or risk
behaviors.
Indicator for each medical
condition and risk behaviors.
If other chronic diseases, please
specify.
If other underlying condition,
please specify.
If other underlying risk behavior,
please specify
If disability (neurologic,
neurodevelopmental, intellectual,
physical, vision or hearing
impairment, please specify.
If psychological or psychiatric
condition, please specify.
Does this case have any tribal
affiliation?
If case has tribal affiliation, provide
tribe name.
If case has tribal affiliation, indicate
if case is an enrolled member.

Trimester at Onset of Illness

If the case-patient was pregnant at
time of illness onset, indicate
trimester of gestation at time of
disease.
Number of Weeks Gestation at Onset If the case-patient was pregnant at
of Illness
time of illness onset, specify the
number of weeks gestation at
onset of illness (1-45 weeks).
Exposure Indicator
Exposure indicator
Listing of the reason(s) the subject
Reason for Testing
was tested for COVID-19
Secondary Diagnosis
Did the patient have another
diagnosis/etiology for their illness?

Secondary Diagnosis Description
Clinical Finding
Clinical Finding Indicator

If patient had another
diagnosis/etiology for their illness,
specify the diagnosis or etiology
Clinical findings associated with the
illness being reported
Indicator for associated clinical
findings

Did the Subject Ever Receive a Vaccine Did the subject ever receive a
Against This Disease
vaccine against this disease?
Number of vaccine doses against
this disease prior to illness onset
Vaccination Doses Prior to Onset
Date of Last Dose Prior to Illness
Date of last vaccine dose against
Onset
this disease prior to illness onset
Comments about the subject's
vaccination history
Vaccine History Comments
Date Left For Travel
Date left for travel
Date of Return from Travel
Date of return from travel
What's case's primary language?
Primary Language
Please indicate for both
hospitalized and not hospitalized
cases.
Clinical information collected from
Information Source for Data
which source(s)? Check all that
apply
Did they have any underlying
Did Underlying Condition(s) Exist
medical conditions and/or risk
behaviors?
Previously Infected Individual

Did the subject meet the case
definition for a previous case
investigation of this disease or
condition?

If the subject previously met the
case definition for the disease or
illness, what was the previously
Previously Reported Jurisdiction Case
submitted sending systemNumber
assigned local ID (case ID) of the
case investigation with which the
subject is associated?
WGS_ID
Genomic sequencing ID number.

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

TBD

CDC Priority (Legacy)

CDC Priority (New)

1
1
1
1
1
1

1
1
1
1
1
1
1
1
1

1
1

1

1

TBD
1

N/A
N/A
N/A

PHVS_YesNoUnknown_CDC

1
1

1

1

TBD
1
N/A

TBD
TBD
N/A

1

1
1

1

TBD
1
TBD
TBD
TBD
PHVS_YesNoUnknown_CDC
TBD
TBD
TBD
N/A
N/A

1
1
1
1
1
1
1
1

1

TBD
PHVS_YesNoUnknown_CDC
N/A
N/A
N/A

1
1
1
1
1

N/A
1
N/A
PHVS_YesNoUnknown_CDC
N/A
PHVS_YesNoUnknown_CDC

1
1
1

1

PHVS_PregnancyTrimester_CDC
2
N/A

PHVS_YesNoUnknown_CDC
TBD

2
1
3

PHVS_YesNoUnknown_CDC
3
N/A
3
PHVS_ClinicalFinding_COVID-19
PHVS_YesNoUnknown_CDC

1
1

PHVS_YesNoUnknown_CDC
N/A
N/A

1
1
3

N/A
N/A
N/A
PHVS_Language_ISO_639-2_Alpha3

3
1
1
2

PHVS_DataReportingSource_COVID-19

3

PHVS_YesNoUnknown_CDC

1

Yes No Unknown (YNU)

1
N/A

N/A

1
2

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

Description

Primary plague type
Animal Contact
Flea bite
Immuncompromised
Date first medical

Classification of primary clinical manifestation of infection
Contact with sick or dead animals
Flea bite
If patient has any immunocompromising conditions, specify
Date that the patient was first seen by medical person.
Did the patient's illness include the symptom of
fever/sweats/chills?
Did the patient's illness include the symptom of
confusion/delirium?
Did the patient's illness include the symptom of
vomiting/diarrhea/abdominal pain?
Did the patient's illness include the symptom of sore throat?
Did the patient's illness include the symptom of cough?
Did the patient's illness include the symptom of chest pain?
Did the patient's illness include the symptom of shortness of
breath?
Did the patient's illness include other symptoms of not listed?
Which other symptoms did the patient's illness include?
Did patient have bubo?
Specify type of bubo
Describe location and appearance of bubo
Did patient have any insect bites/skin ulcer

Fever/sweats/chills
Confusion/delirium
Vomiting/diarrhea/abdominal pain
Sore throat
Cough
Chest Pain
Shortness of breath
Other_symptoms
Other_symptoms_specify
Bubo
Type of Bubo
Location/description Bubo
Insect bites/skin ulcer
Location/description insect bites/skin
ulcer
Chest X-ray
Antibiotic
Antibiotic start date
Illness outcome
Primary plague type
Secondary pneumonic plague
Y. pestis cultured
Specimen source
Date specimen collected
Y. pestis detected
Test performed
Specimen source
Date specimen collected
Serology
First Serum titer
Second Serum titer
Date first serum drawn
Date second serum drawn

Describe location and appearance of insect bites/skin ulcer
Results of chest x-ray
Did patient receive an effective antibiotic for illness?
Date each antibiotic started
Outcome of illness
Classification of primary clinical manifestation of infection
Did patient have secondary pneumonic plague?
Was Y. pestis cultured?
Source of culture
Date specimen was collected
Was Y. pestis detected by other tests?
Test used to detect Y. pestis
Specimen source in which Y. pestis was detected
Date of specimen collection
Serology results
Titer of first serum specimen
Titer of second serum specimen
Date first serum drawn
Date second serum drawn

Epi-linked to any other plague cases
Likely location of exposure
Animal contact
Nature of contact
Type of animal contact
Flea bite or insect bites
Wild animal
Domestic animal
Evidence of infected animals or fleas
Specify infected animals or fleas
Other exposure
Comments
Person to person transmission

Was this illness epi-linked to any other plague cases?
Most likely location of exposure
Did patient have any animal contact in the 2 weeks preceding
illness?
Nature of animal contact in the 2 weeks preceding illness
Was animal domestic or wild
Did patient have flea or insect bites in the 2 weeks preceding
illness?
Specify wild animal that patient had contact with in the 2 weeks
preceding illness
Specify domestic animal that patient had contact with in the 2
weeks preceding illness
Evidence of infected animals or fleas in the likely exposure
location
Describe evidnece of Y. pestis infected animals or fleas in likely
exposure location
Specify any other exposures in the two weeks preceding illness
Additional comments
Evidence of person to person transmission from a known plague
patient

Value Set Code. Search in PHIN
CDC Priority
VADS using the following link
(https://phinvads.cdc.gov/vads/Sear
chHome.action)
TBD
TBD
TBD
N/A
N/A
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

P
P
P
P
P
P
P
P
P
P
P

PHVS_YesNoUnknown_CDC
N/A
PHVS_YesNoUnknown_CDC
TBD
N/A
PHVS_YesNoUnknown_CDC

P
P
P
P
P
P
P

N/A
TBD
TBD
N/A
TBD
TBD
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
N/A
N/A
PHVS_YesNoUnknown_CDC
N/A
N/A
N/A
TBD
N/A
N/A
N/A
N/A

P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P

PHVS_YesNoUnknown_CDC
TBD

P
P

PHVS_YesNoUnknown_CDC
TBD
TBD

P
P
P

PHVS_YesNoUnknown_CDC

P

N/A

P

N/A

P

PHVS_YesNoUnknown_CDC

P

N/A
N/A
N/A

P
P
P

PHVS_YesNoUnknown_CDC

P

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
Signs and Symptoms
Signs and Symptoms Indicator
Highest Measured Temperature
Temperature Units
Antibiotics given
Treatment Start Date
Treatment End Date

Treatment Duration
Hospital ICU
Laboratory Testing Performed
Laboratory Confirmed
Test Manufacturer
Autopsy Specimen Type
Autopsy Result
Date of Autopsy
Autopsy Laboratory Name
Industry at Date of Onset
Personal Protective Equipment
Respiratory Protective Equipment
Annual Respirator Fit Testing and
Training
Glove Material
Contact Type
Bird Type
Bird Species
Number of Birds
Illness Onset Age
Illness Onset Age Units

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
Indicate what symptoms of interest the patient had during the course of the illness
Indicator for associated sign and symptom
What was the subject's highest measured temperature during this illness?
Units for highest measured temperature
Did the subject take antibiotics as treatment for this illness?
Start date of antibiotic
Stop date of antibiotic

Number of days the patient actually took the antibiotic
During any part of the hospitalization, did the subject stay in an Intensive Care Unit
(ICU) or a Critical Care Unit (CCU)?
Was laboratory testing done to confirm the diagnosis?
Was the case laboratory confirmed?
Test Manufacturer
Type of autopsy specimen
Autopsy result
Date of autopsy (date autopsy specimen collected)
Autopsy Laboratory Name
Industry at date of onset
At the time of exposure, which of the following personal protective equipment was
used by the patient?
If respiratory protective equipment was used at the time of exposure, specify what
kind
Does the patient get annual respirator fit testing and training?
If gloves were used, specify glove material
Indicate which of the following contacts patient had during 5 weeks prior to onset
What type of bird did the patient have contact with during the 5 weeks prior to onset?
Bird species
Approximate number of birds
Illness onset age
Illness onset age units

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

CDC Priority

PHVS_SignsSymptoms_RIBD

P

PHVS_YesNoUnknown_CDC
N/A
PHVS_TemperatureUnit_UCUM
PHVS_YesNoUnknown_CDC
N/A
N/A

P
P
P
P
P
P

N/A
PHVS_YesNoUnknown_CDC

P
P

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
N/A
PHVS_SpecimenSite_RIBD
N/A
N/A
N/A
PHVS_Industry_CDC_Census2010
PHVS_PersonalProtectiveEquipment_RIBD

P
P
P
P
P
P
P
P
P

PHVS_RespiratoryProtectiveEquipment_RIBD

P

PHVS_YesNoUnknown_CDC

P

PHVS_GloveMaterial_RIBD
PHVS_ContactType_RIBD
PHVS_BirdType_RIBD

P
P
P

N/A
N/A
N/A
PHVS_AgeUnit_UCUM

P
P
P
P

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
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
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
Part of Outbreak

Date of Return from Travel
Case Patient a Healthcare Worker
Previous case diagnosed by
Vaccination Doses Prior to Onset
Date of Last Dose Prior to Illness
Onset
Vaccine History Comments
Age at rash onset
Age units at rash onset
Age units at previous diagnosis
Length of time in U.S.
Length of time in U.S. Units
International Destination(s) of
Recent Travel

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
Is this case part of an outbreak of 3 or more

Date of return from most recent travel
Was the case patient a healthcare provider (HCP) at illness onset?
Who diagnosed previous case?
Number of vaccine doses against this disease prior to illness onset
Date of last vaccine dose against this disease prior to illness onset
Comments about the subject's vaccination history
Age at rash onset
Age units at rash onset
Age units at previous diagnosis
Length of time in U.S.
Length of time in U.S. Units
List any international destinations of recent travel.

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

Description

Formtype

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

CDCNUM
StateEpiNumber
SLABSID
SLABSID2

SpecNumber
SpecNumber2

SpecNumber3

NARMS Isolate Identification
Number- for dulplicate
sample from a single patient

Year

Year of report (based on date
onset)
Date Form was entered into
database
Date Form was received to
CDC
First three letters of patient's
last name
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

Date Entered
Date Rec CDC
Name
Foodhand

Citizen

Othcitzn
Ill

Dtonset

Outcome

Outcome of case
(1=Recovered 2=Died
3=didn't answer 9=unknown)

Dtisol

Date Salmonella first isolated

Site

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!

Othsite
Serotype
Sensi

Other site of isolation

Ampr

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)

Chlorr

Was sensitivity testing done?
(1=Yes 2=No 9=unknown
3=didn't answer)

Tmpsmxr

Resistant to trimethoprimsulfamethoxazole on form 3?
(1=Yes 2=No 7=not tested
3=didn't answer 9=unknown)

quinol

Resistant to fluoroquinolone
on form 3? (1=Yes 2=No
7=not tested 3=didn't
answer 9=unknown)

Ceft

Resistant to ceftriaxone
(1=Yes 2=No 9=unknown)
Case occur as part of
outbreak? (1=Yes 2=No
9=unknown 3=didn't answer)

outbreak

vac5yr

Vaccinated within 5 yrs?
(1=Yes 2=No 9=unknown
3=didn't answer)

stanvax

Standard Killed typhoid shot
(1=Yes 2=No, 9=unknown,
3=didn't answer)

yrstanvx

Year standard vaccine
received
Oral Ty 21a or Vivotof four
pill series (1=Yes 2=No,
9=unknown, 3=didn't answer)

ty21vax

yrty21

Year of Oral Ty 21a or Vivotof
four pill series received

vicps

VICPS or Typhium VI shot
(1=Yes 2=No, 9=unknown,
3=didn't answer)
Year VICPS or Typhium VI
shot received
Travel outside 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)
Visiting relatives or friends is
purpose of international
travel(1=Yes 2=No
9=unknown 3=didn't answer)

yrvicps
outus

country1
country2
country3
country4
country1oth
country2oth
country3oth
country4oth
dtentus
business

tourism

visitfam

immigrat

Immigration to the US is
purpose of international
travel (1=Yes 2=No
9=unknown 3=didn't answer)

othtrav

travreas
anycarr

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)

prevcarr

Carrier previously known to
health dept (1=Yes 2=No
9=unknown 3=didn't answer)

comment
dtform

Comments
Date PH Dept completed
form
If the travel exposure window
used by the jurisdiction is not
30 days. Specify the time
interval in days here.
Otherwise, leave blank.

Specify Different Travel Exposure Window

health care worker
day care attendee
day care worker
PulseNet ID
WGS ID Number
Date Of Arrival To Travel Destination
Travel State

Was the patient a health care
provider?
Was the patient a health care
attendee?
Was the patient a day care
provider?
State lab ID submitted to
PulseNet
Whole Genome Sequencing
(WGS) ID Number
Date of arrival to travel
destination
Domestic destination, state(s)

Value Set Code. Search in PHIN VADS
CDC Priority
using the following link
(Legacy)
(https://phinvads.cdc.gov/vads/SearchHo
me.action)
N/A

N/A
N/A
N/A
N/A

P
P
P
P

P
N/A

P

N/A
P
N/A
P
N/A
N/A
N/A
N/A

P
P
P
P

PHVS_YesNoUnknown_CDC
P

N/A
PHVS_YesNoUnknown_CDC

N/A

P
P

P
P

CDC
Priority
(New)

PHVS_ConditionStatus_FDD
P
N/A

P

PHVS_SpecimenCollectionSource_FDD

N/A
N/A
PHVS_YesNoUnknown_CDC

P
P
P

P
PHVS_YesNoUnknown_CDC
P
PHVS_YesNoUnknown_CDC

P
PHVS_YesNoUnknown_CDC

P
PHVS_YesNoUnknown_CDC

P
PHVS_YesNoUnknown_CDC

P

PHVS_YesNoUnknown_CDC
P
PHVS_YesNoUnknown_CDC
P

PHVS_YesNoUnknown_CDC
P
N/A

P

PHVS_YesNoUnknown_CDC
P
N/A
P
PHVS_YesNoUnknown_CDC
P
N/A

P

PHVS_YesNoUnknown_CDC

PHVS_Country_ISO_3166-1
PHVS_Country_ISO_3166-1
PHVS_Country_ISO_3166-1
PHVS_Country_ISO_3166-1
PHVS_Country_ISO_3166-1
PHVS_Country_ISO_3166-1
PHVS_Country_ISO_3166-1
PHVS_Country_ISO_3166-1
N/A

P
P
P
P
P
P
P
P
P
P

PHVS_TravelPurpose_FDD
P
PHVS_TravelPurpose_FDD
P
PHVS_TravelPurpose_FDD

P
PHVS_TravelPurpose_FDD

P

PHVS_TravelPurpose_FDD

N/A

P
P

PHVS_YesNoUnknown_CDC

P

PHVS_YesNoUnknown_CDC
N/A
N/A

P
P
P

N/A

P
PHVS_YesNoUnknown_CDC

P

PHVS_YesNoUnknown_CDC

P

PHVS_YesNoUnknown_CDC
N/A

P
1

N/A

1

N/A

3

PHVS_State_FIPS_5-2

3

Label/Short Name

Description

Formtype

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

CDCNUM
StateEpiNumber
SLABSID
SLABSID2

SpecNumber
SpecNumber2

SpecNumber3

Year
Date Entered
Date Rec CDC
State
Name
DOB
Age
Sex
Foodhand

Citizen

Othcitzn
Ill

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!

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

Dtonset
Hosp
Hospdays

Outcome

Dtisol
Site

Othsite
Serotype
Sensi

Ampr

Chlorr

Tmpsmxr

quinol

Ceft
outbreak

vac5yr

stanvax

yrstanvx

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 trimethoprimsulfamethoxazole 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)
Resistant 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

ty21vax

yrty21
vicps

yrvicps
outus

country1
country2
country3
country4
country1oth
country2oth
country3oth
country4oth
dtentus
business

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 outside 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

Tourism is purpose of
international travel(1=Yes 2=No
9=unknown 3=didn't answer)

visitfam

Visiting 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

immigrat

othtrav

travreas
anycarr

Reason for other travel
Case traced to typhoid carrier?
(1=Yes 2=No 9=unknown
3=didn't answer)

prevcarr

comment
dtform
Specify Different Travel Exposure
Window

health care worker
day care attendee
day care worker
PulseNet ID
WGS ID Number
Date Of Arrival To Travel
Destination
Travel State

Carrier previously known to
health dept (1=Yes 2=No
9=unknown 3=didn't answer)
Comments
Date PH Dept completed form
If the travel exposure window
used by the jurisdiction is not
30 days. Specify the time
interval in days here.
Otherwise, leave blank.

N/A

Was the patient a health care PHVS_YesNoUnknown_CDC
provider?
Was the patient a health care PHVS_YesNoUnknown_CDC
attendee?
Was the patient a day care
PHVS_YesNoUnknown_CDC
provider?
State lab ID submitted to
N/A
PulseNet
Whole Genome Sequencing
N/A
(WGS) ID Number
Date of arrival to travel
N/A
destination
Domestic destination, state(s) tr PHVS_State_FIPS_5-2

CDC Priority
(Legacy)

CDC
Priority
(New)

P

P
P
P
1
1
3
3

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
Occupation/Industry/Place of
Business
Child care attendee
Long term care facility resident
Contact of a Salmonellosis case
Method(s) of laboratory testing
Name of test
Name of test manufacturer
Probable case from CIDT testing

Probable case from Epi-linkage
Reported symptoms and signs of
illness
WGS (Whole-Genome Sequencing)
ID
Specify Different Travel Exposure
Window
PulseNet ID
Date Of Arrival To Travel Destination
Date Of Departure From Travel
Destination
Reason for travel related to current
illness

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
Is patient employed in a high risk occupation (e.g., food handler, healthcare worker,
daycare worker)?
Did patient have a high risk exposure related to child care facility?
Did patient have a high risk exposure related to residence in a long term care facility?
Did patient have a high risk exposure related to contact with a Salmonellosis case?
Type of laboratory testing performed
Name of laboratory test performed
Name of test manufacturer
Probable case status confirmed by CIDT testing

Probable case confirmed by Epi-linkage
Symptoms and signs associated with illness
The identifier used in PulseNet for the whole genome sequenced isolate that
corresponds to the reported case
If the travel exposure window used by the jurisdiction is different from that stated in
the travel exposure questions, specify the time interval in days here. Otherwise, leave
blank.
State lab ID submitted to PulseNet
Date of arrival to travel destination
Date of departure from travel destination
Reason for travel related to current illness

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

CDC Priority
(Legacy)

CDC Priority
(New)

N/A

P

N/A
N/A

1
3

N/A

3

PHVS_TravelPurpose_FDD

3

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
International travel in the 7 days
prior to onset
Occupation/Industry/Place of
Business
Child care attendee
Long term care facility resident
Contact of a Shigellosis case
Method(s) of laboratory testing
Name of test
Name of test manufacturer
Probable case from CIDT
Probable case from Epi-linkage
Reported symptoms and signs of
illness
WGS (Whole-Genome Sequencing)
ID
Specify Different Travel Exposure
Window
Did The Case Travel Domestically
Prior To Illness Onset?
Travel State
International Destination(S) Of
Recent Travel
PulseNet ID
Date Of Arrival To Travel Destination
Date Of Departure From Travel
Destination
Reason for travel related to current
illness

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
Did patient travel internationally within 7 days of illness onset?
Is patient employed in a high risk occupation (e.g., food handler, healthcare worker,
daycare worker)?
Did patient have a high risk exposure related to attendance at a child care facility?
Did patient have a high risk exposure related to residence in a long term care facility?
Did patient have a high risk exposure related to contact with a Shigellosis case?
Type of laboratory testing performed
Name of laboratory test performed
Name of test manufacturer
Probable case status confirmed by CIDT (Culture Independent Diagnostic Testing)
Probable case confirmed by Epi-linkage
Symptoms and signs associated with illness
The identifier used in PulseNet for the whole genome sequenced isolate that
corresponds to the reported case
If the travel exposure window used by the jurisdiction is different from that stated in
the travel exposure questions, specify the time interval in days here. Otherwise, leave
blank.
Did the case patient travel domestically within program specific timeframe?
Domestic destination, state(s) traveled to
International destination or countries the patient traveled to
State lab ID submitted to PulseNet
Date of arrival to travel destination
Date of departure from travel destination
Reason for travel related to current illness

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

CDC Priority (Legacy)

N/A

P

PHVS_YesNoUnknown_CDC

P

PHVS_State_FIPS_5-2
PHVS_Country_ISO_3166-1

P
P

N/A
N/A
N/A
PHVS_TravelPurpose_FDD

CDC Priority (New)

1
2
2
3

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

Ocular Manifestations

Otic Manifestations
Late Clinical Manifestations (tertiary
syphilis)

Transgender
Sexual Orientation

Date Treatment was Prescribed
Date Treatment was Administered
Medication Administered
Medication Administered Dose
Treatment Duration
Type of Complication
Type of Complication Indicator
Treatment Dosage
Treatment Dosage Unit
Treatment Route of Delivery
Treatment Drug Frequency
Treatment Drug Frequency Unit
Treatment Duration Units
Drug Use Route of Delivery

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

Infection of any eye structure with T. pallidum, as evidenced by manifestations
including posterior uveitis, panuveitis, anterior uveitis, optic neuropathy, and retinal
vasculitis.
Infection of the cochleovestibular system with T. pallidum, as evidenced by
manifestations including sensorineural hearing loss, tinnitus, and vertigo.
Late clinical manifestations of syphilis (tertiary syphilis) may include inflammatory
lesions of the cardiovascular system, skin, bone, or other tissue. Certain neurologic
manifestations (e.g., general paresis and tabes dorsalis) are late clinical manifestations
of syphilis.
Patient identified as transgender (i.e., an individual’s personal sense of being male,
female, or transgender).
Patient identified sexual orientation (i.e., an individual's physical and/or emotional
attraction to another individual of the same gender, opposite gender, or both
genders).
Date treatment associated with the condition was prescribed
Date treatment associated with the condition was administered
Name of the antibiotic administered
Dose of the antibiotic administered
Prescribed duration of antibiotic
Complications associated with the illness being reported
Indicator for associated complication
Dose of the treatment associated with the condition
Unit of measure for the treatment associated with the condition
Route of delivery of treatment
Frequency of treatment drug
Unit of measure for the frequency of treatment associated with the condition
Unit of measure for the duration of treatment associated with the condition
Route of delivery of drug(s) used

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

CDC Priority (Legacy)

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

TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD
TBD

O
O
O
O
O
O
O
O
O
O
O
O
O
O

CDC Priority (New)

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
Probable – laboratory-diagnosed
Probable – epi-linked
TTP
Ill contact
Gourmet cheese
Specify other leafy greens
Sprouts location
Sprouts brand
Treated recreational water
Untreated recreational water
Treated recreational water location
Untreated recreational water
location
Other related diagnosis
Specify other related diagnosis
Shopper card consent
Ground beef at home brand
Steak at home brand
Steak at home frozen

Steak at home fresh
Bison brand
Wild game brand
Dried meat brand
Other dried meat brand
Pork
Pork at home
Pork at home purchase location
Pork at home brand
Pork at home ground
Pork at home whole
Pork at home other form
Specify other form of pork at home
Pork away from home
Pork away from home location
Pork away from home dish
Raw milk location
Raw milk brand
Raw cheese
Raw cheese brand
Raw cheese aged
Gourmet cheese location
Gourmet cheese brand
Raw juice location
Raw juice brand
Other raw dairy product
Specify other raw dairy product
Other raw dairy product location
Other raw dairy product brand
Raw dough
Leafy greens
Leafy greens location
Leafy greens brand
Loose leafy greens
Prepackaged leafy greens
Cabbage
Cabbage location
Cabbage brand
Arugula
Arugula location
Arugula brand
Kale
Kale location
Kale brand
Premade salad
Premade salad location
Premade salad brand

Other prepackaged leafy greens
Other prepackaged leafy greens
location
Other prepackaged leafy greens
brand
Other leafy greens location
Other leafy greens brand
Herbs
Specify herbs
Herbs location
Herbs brand
Specify petting zoo
Specify type of livestock
Specify fair
Pet
Specify pet
Specify institution
Treated recreational water type
Untreated recreational water type
Occupation
Food allergy
Special diet
Specify Different Exposure Window

Specify Different Travel Exposure
Window
WGS ID Number
Reason for travel related to current
illness

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
Probable case is laboratory-diagnosed
Probable case is epidemiologically linked
Patient had a diagnosis of TTP (Thrombotic thrombocytopenic purpura)
Patient had close contact with anyone with diarrhea or vomiting in the 7 days prior to
illness onset
Patient consumed artisanal or gourmet cheese in the 7 days before illness onset
Specify other leafy greens
Purchase location of sprouts
Brand and variety of sprouts
Visit or swim in any treated recreational water facilities in 7 days prior to illness onset
Visit or swim in any untreated recreational water facilities in 7 days prior to illness
onset
Location of treated recreational water facilities
Location of untreated recreational water facilities
Other related diagnosis
Specify other related diagnosis
Consent to retrieve purchases based on shopper card information
Brand and variety of ground beef consumed at home
Brand and variety of steak consumed at home
Steak consumed at home was purchased frozen

Steak consumed at home was purchased fresh
Brand and variety of bison
Brand and variety of wild game
Brand and variety of dried or fermented meat
Brand and variety of other dried or fermented meat
Patient consumed pork in 7 days prior to illness onset
Patient consumed pork at home in 7 days prior to illness onset
Purchase location of pork consumed at home
Brand and variety of pork consumed at home
Pork consumed at home was ground
Pork consumed at home was whole pig
Pork consumed at home was other form
Specify other type of pork consumed at home
Patient consumed pork away from home in 7 days prior to illness onset
Purchase location of pork consumed away from home
Dish in which pork was consumed away from home
Purchase location of raw milk
Brand and variety of raw milk
Purchase location of cheese made from raw milk
Brand and variety of cheese made from raw milk
Cheese made from raw milk was aged for 60 days
Purchase location of artisanal or gourmet cheese
Brand and variety of artisanal or gourmet cheese
Purchase location of unpasteurized juice or cider
Brand and variety of unpasteurized juice or cider
Patient consumed any other unpasteurized dairy product in 7 days prior to illness
onset
Specify other unpasteurized dairy product
Purchase location of other unpasteurized dairy product
Brand and variety of other unpasteurized dairy product
Patient ate, tasted, or licked uncooked or unbaked dough or batter
Patient consumed fresh, uncooked leafy greens in 7 days prior to illness onset
Purchase location of fresh, uncooked leafy greens
Brand and variety of fresh, uncooked leafy greens
Patient consumed loose fresh, uncooked leafy greens
Patient consumed prepackaged fresh, uncooked leafy greens
Patient consumed cabbage in 7 days prior to illness onset
Purchase location of cabbage
Brand and variety of cabbage
Patient consumed arugula in 7 days prior to illness onset
Purchase location of arugula
Brand and variety of arugula
Patient consumed kale in 7 days prior to illness onset
Purchase location of kale
Brand and variety of kale
Patient consumed pre-made, single-serving salads in 7 days prior to illness onset
Purchase location of pre-made, single-serving salads
Brand and variety of pre-made, single-serving salads

Patient consumed other pre-packaged leafy greens or salad kits
Purchase location of other pre-packaged leafy greens or salad kits
Brand and variety of other pre-packaged leafy greens or salad kits
Purchase location of other leafy greens
Brand and variety of other leafy greens
Patient consumed fresh herbs in 7 days prior to illness onset
Specify fresh herbs
Purchase location of fresh herbs
Brand and variety of fresh herbs
Specify petting zoo
Specify type of livestock
Specify fair or event with animals
Patient has a pet of their own
Specify pet
Specify institution
Types of treated recreational water facilities
Types of untreated recreational water facilities
Patient's occupation
Does the patient have a food allergy?
Is the patient on a special diet?
If the epidemiologic exposure window used by the jurisdiction is different from that
stated in the exposure questions, specify the time interval in days here. Otherwise,
leave blank.
If the travel exposure window used by the jurisdiction is different from that stated in
the travel exposure questions, specify the time interval in days here. Otherwise, leave
blank.
Whole Genome Sequencing (WGS) ID Number
Reason for travel related to current illness

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

CDC Priority (Legacy)

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

N/A

P

N/A

P

N/A
PHVS_TravelPurpose_FDD

CDC Priority (New)

1
3

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

Physician Name
Physician Phone
Clinical Manifestation
Clinical Manifestation Indicator
Experienced Complication
Type of Complication
Patient Immunocompromised
Treatment Drug Indicator
Medication Administered
Date Treatment or Therapy Started
Treatment Duration
Occupation related to exposure
Travel
International Destination(s) of
Recent Travel
Travel State
Travel County
Date of Arrival to Travel Destination
Date of Departure from Travel
Destination
Tick Bite Location
Tick Bite Date
Blood Transfusion
Blood Transfusion Date
Transfusion Associated
Transfused Product
Organ Transplant
Transplant type
Transplant date
Transplant associated infection
Blood Donor
Blood Donation Date
Blood Donor Implicated During
Investigation
Donated Product
Blood bank notified
Co-infection
Co-infection type

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)

Name of subject's clinician/provider of care,Provide the name in the following
format:,<last name>, <first name>
Phone number of subject's clinician/provider of care
Clinical manifestation of TBRD
For each clinical manifestation reported, indicate (YNU) whether the subject
developed the specified manifestation as a result of the illness.
Did the subject experience any complications due to this episode?
If the subject experienced complications due to this episode, what was the
complication?
At the time of diagnosis, was the subject immunocompromised?
Did the subject receive antimicrobial treatment for this infection?
What antibiotic did the patient receive for this episode?
Date the treatment was initiated
Number of days the patient actually took the antibiotic referenced
Is the subject's current occupation related to the exposure?
In the two weeks before symptom onset or diagnosis (use earlier date), did the subject
travel out of their county, state, or country of residence?
International destination, countries traveled to
Domestic destination, state(s) traveled to
Intrastate destination, counties traveled to
If the subject traveled, when did they arrive to their travel destination?
If the subject traveled, when did they depart from their travel destination?
If subject noticed tick bite, where did the bite occur (geographic location)?
If subject noticed tick bite, when did the bite occur?
In the year before symptom onset or diagnosis (use earlier date), did the subject
receive a blood transfusion?
Date(s) of blood transfusion(s)
Was the subject’s infection transfusion associated?
If a transfused blood product was implicated in an investigation, specify which type(s)
of product.
In the year before symptom onset or diagnosis (use earlier date), did the subject
receive an organ transplant(s)?
If the subject received an organ transplant, what was the organ?
Date(s) of organ transplant(s)
Was the subject's infection transplant-related?
Did the subject donate blood in the 30 days prior to symptom onset?
Date(s) of blood donation(s)
Was the subject a blood donor identified during a transfusion investigation (i.e., had
positive test results and was linked to an infected recipient)?
If a donated blood product was implicated in an investigation, specify which type(s) of
product.
Was the blood bank/hospital/transplant service notified?
Was the subject diagnosed with a co-infection?
Specify coinfection

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

CDC Priority

N/A

P

N/A
PHVS_ClinicalManifestation_TBRD
PHVS_YesNoUnknown_CDC

P
P
P

PHVS_YesNoUnknown_CDC
PHVS_Complication_TBRD

P
P

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_MedicationReceived_TBRD

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

P
P
P
P
P
P
P

PHVS_YesNoUnknown_CDC

P

PHVS_State_FIPS_5-2
PHVS_County_FIPS_6-4

P
P
P
P

PHVS_YesNoUnknown_CDC

P
P
P

PHVS_YesNoUnknown_CDC
PHVS_BloodProduct_CDC

P
P
P

PHVS_YesNoUnknown_CDC

P

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

P
P
P
P
P
P

PHVS_BloodProduct_CDC

P

PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

O
P
P

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

Travel History
International Destination(s) of
Recent Travel
Travel State
Date of Arrival to Travel Destination
Date of Departure from Travel
Destination
Epi-Linked
Where Meat Tested
Meat Comments

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

In the 8 weeks before onset of illness, did the subject travel out of their state or
country of residence?
International destination or countries the case-patient traveled to in the 8 weeks
before onset of illness
Domestic destination or state(s) the case-patient traveled to in the 8 weeks before
onset of illness
Date of arrival to travel destination
Date of departure from travel destination
Is this case epi-linked to another confirmed or probable case?
Where was the suspected meat tested?
Use this field, if needed, to communicate anything unusual about the suspect meat,
which is not already covered with the other data elements (e.g., additional details
about where eaten, if consumed while traveling outside of the U.S., where wild game
was hunted, etc.).

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
TB State Case Number

Value Set Code.
CDC Priority
Search in PHIN
VADS using the
following link
(https://phinvads.cd
c.gov/vads/SearchH
Description
ome.action)
State case number N/A
P
for the case specific
to TB investigations
(4 digit report year
+ 2 letter state + 9
digit alphanumeric
number)

City or County Case
Number

City or county case N/A
number assigned to
this case

Birth Sex

What was the
PHVS_Sex_MFU
P
patient's sex at
birth?
Has this case
PHVS_CaseCountSta P
already been
tus_TB
counted by another
reporting area?

Previously Counted
Case

P

Previously Reported
State Case Number

P
If case previously N/A
counted, provide
the state case
number from the
other reporting
area.
Country of Verified Case If the case was
PHVS_BirthCountry_ P
previously reported CDC
by another country,
specify the country.

Patient Address City

Patient address city N/A

Inside City Limits

Is the patient's
residence within
city limits?

P

PHVS_YesNoUnkno P
wn_CDC

Census Tract of CasePatient Residence

Detailed Race

Date Arrived in US

Census tract where N/A
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.
Provide the
PHVS_Race_CDC
detailed race
information for the
patient.
If country of birth is N/A
NOT United States,
regardless of
citizenship, indicate
the date when the
patient first arrived
in the US.

P

P

P

US Born

Was the patient
PHVS_YesNoUnkno P
eligible for US
wn_CDC
citizenship at birth?

Primary Guardian(s)
Country of Birth

Indicates the birth PHVS_BirthCountry_ P
country of the
CDC
primary guardian(s)
of patient (pediatric
[<15 years old]
cases only)

Remain in US After
Report

If not US reporting PHVS_YesNoUnkno P
area, did patient
wn_CDC
remain in the
United States for >=
90 days after report
date?
What was the initial PHVS_PrimaryReaso P
reason the patient nForEvaluation_TB
was evaluated for
TB?

Initial Reason for
Evaluation

Test Type

Epidemiologic
PHVS_LabTestType_ P
interpretation of
TB
the type of test(s)
performed for this
case. Please
provide a response
for each of the
main test types
(culture, smear,
pathology/cytology
, NAA, TST, IGRA,
HIV, diabetes) If
test was not done
please indicate so.

Epidemiologic
PHVS_LabTestInterp P
interpretation of
retation_TB
the results of the
test(s) performed
for this case - This
is a qualitative test
result. (e.g.,
positive, detected,
negative)
Date/Time of Lab Result Date result sent
N/A
P
from reporting
laboratory. Time of
result is an optional
addition to date.
Test Result

Specimen Source Site

This indicates the PHVS_MicroscopicE P
anatomical source xamCultureSite_TB
of the specimen
tested.
Specimen Collection
Date of collection N/A
P
Date/Time
of laboratory
specimen used for
diagnosis of health
event reported in
this case report.
Time of collection is
an optional
addition to date.
Test Result Quantitative Quantitative test N/A
P
result value
Result Units
Units of measure PHVS_UnitofMeasur P
for the Quantitative e_TB
Test Result Value

Type of Chest Study

Result of Chest Study
Evidence of Cavity

Indicate the type of PHVS_TypeofRadiol P
chest study
ogyStudy_CDC
performed. Please
provide a response
for each of the
main test types
(plain chest
radiograph, chest
CT Scan) and if test
was not done
please indicate so.
Result of chest
PHVS_ResultofRadio P
diagnostic testing logyStudy_TB
Did test show
PHVS_YesNoUnkno P
evidence of cavity? wn_CDC

Did test show
PHVS_YesNoUnkno P
evidence of miliary wn_CDC
TB?
Date of the chest N/A
Date of Chest Study
P
diagnostic study
Patient Epidemiological Exposed risk factors PHVS_Epidemiologic P
Risk Factors
for the patient alRiskFactors_TB
Please provide a
response for all risk
factors in the value
set with an
associated
indicator
Evidence of Miliary TB

Patient Epidemiological Provide a response PHVS_YesNoUnkno P
Risk Factors Indicator for each value in
wn_CDC
the patient
epidemiological risk
factors value set

Type of Correctional
Facility

If patient was a
PHVS_CorrectionalF P
Resident of
acilityType_NND
Correctional Facility
at Diagnostic
Evaluation, indicate
the type of
correctional facility.

Type of Long-Term Care If patient was a
PHVS_LongTermCar P
Facility
Resident of Long
eFacilityType_NND
Term Care Facility
at Diagnostic
Evaluation, indicate
the type of long
term care facility.
What is the
PHVS_SmokingStatu P
patient's current
s_CDC
tobacco smoking
status?
Patient lived outside of Residence or Travel PHVS_YesNoUnkno P
in countries other wn_CDC
US for more than 2
than the United
months
States, Canada,
Australia, New
Zealand, or
countries in
northern or
western Europe for
>60 consecutive
days at any point in
the patient's
lifetime.
Identified During
Was the patient
PHVS_YesNoUnkno P
Contact Investigation identified during
wn_CDC
the contact
investigation
around the likely
source case?
If patient was
Evaluation During
PHVS_YesNoUnkno P
Contact Investigation identified during
wn_CDC
contact
investigation, was
the patient
evaluated for TB
during the contact
investigation?
Linked Case Number
P
State case numbers N/A
for
epidemiologically
linked cases
Date Treatment or
Date the initial
N/A
P
Therapy Started
treatment regimen
was started
Smoking Status

Treatment
Administration Type

Choose all
PHVS_TreatmentAd P
treatment
ministrationType_T
administration
B
types that apply to
the case, such as
DOT, eDOT, or SAT.

Date Treatment or
Therapy Stopped
Case Verification
Category

Date treatment
N/A
P
stopped
Indicates case
PHVS_CaseVerificati P
verification criteria on_TB
result based on
factors such as
culture results,
smear results,
major and
additional sites of
the disease, x-ray
results, TST, IDR,
reason therapy was
stopped.
Was the patient
PHVS_GeneralCondi P
alive or dead at the tionStatus_TB
time of diagnostic
evaluation?

Status at Diagnosis of
TB

Site of Disease

Contact Investigation

Diagnosis Type

History of Previous
Illness

What was the site PHVS_AdditionalDis P
of the patient's TB easeSite_TB
disease?
Was a contact
PHVS_YesNoUnkno P
investigation
wn_CDC
conducted around
this case?
Previous TB or LTBI PHVS_DiagnosisTyp P
Diagnosis - Provide e_TB
only 1 response for
LTBI, multiple
responses for TB
are allowed

Did the subject
PHVS_YesNoUnkno P
have a history of TB wn_CDC
or LTBI?
Date of Previous Illness Date of previous
N/A
P
diagnosis
Previous State Case
Previous TB or LTBI N/A
P
Number
State Case Number

Completed Treatment
for Previous Diagnosis

Completed
PHVS_YesNoUnkno P
Treatment for
wn_CDC
Previous Diagnosis
Was the patient
Initially Treated with
PHVS_YesNoUnkno P
initially treated
RIPE
wn_CDC
with the
recommended
four-drug therapy
(RIPE)?
Reason Not Treated
PHVS_ReasonNotTr P
If not initially
with RIPE
treated with RIPE, eatedwithRIPE_TB
why not?
Reason Therapy
Indicate the
PHVS_ReasonThera P
Stopped
primary reason that pyStopped_TB
therapy was
stopped or never
started; specify this
data when the case
is closed.
Reason Therapy
Select the reason PHVS_TherapyExten P
Extended
dedReason_TB
the therapy
extended beyond
12 months.
Final Disease Outcome Final TB disease
PHVS_FinalTreatme P
case outcome
ntOutcome_TB
Initial Drug Regimen
Initial drug regimen PHVS_Medications_ P
for the patient:
TB
Please provide a
response for each
of the values in the
value set using the
associated
indicator.
Initial Drug Regimen
Indicator
Isolate Submitted for
Genotyping
Accession Number for
Genotyping

Indicator response
for the initial drug
regimen question
Was an isolate
submitted for
genotyping?
If an isolate was
submitted for
genotyping to a
CDC laboratory
only, list the
accession number
for genotyping.

PHVS_YesNoUnkno P
wn_CDC
PHVS_YesNoUnkno P
wn_CDC
N/A

P

Phenotypic Drug
Susceptibility
Completed

Molecular Drug
Susceptibility
Completed

Was
PHVS_YesNoUnkno P
phenotypic/growth wn_CDC
-based drug
susceptibility
testing done?
Was
PHVS_YesNoUnkno P
genotypic/molecula wn_CDC
r drug susceptibility
testing done?

Antimicrobial
Antimicrobial
PHVS_Susceptibility P
Susceptibility Test Type Susceptibility Test TestType_TB
Type of TB drugs.
For the initial
susceptibility
testing please send
a response for each
values in the value
set. Changes in
susceptibility
should be reported
for each individual
drug when change
is identified.

Antimicrobial
N/A
Antimicrobial
Susceptibility Specimen Susceptibility
Collection Date
Specimen
Collection Date
Antimicrobial
Antimicrobial
N/A
Susceptibility Result
susceptibility result
Reported Date
reported date

P

P

Antimicrobial
Antimicrobial
PHVS_MicroscopicE P
Susceptibility Specimen Susceptibility
xamCultureSite_TB
Specimen Type
Type
(e.g. Exudate,
Blood, Serum,
Urine)
Antimicrobial
PHVS_Susceptibility P
Antimicrobial
Susceptibility Test
Susceptibility Test TestResultQuantitati
Interpretation
Interpretation (e.g. ve_TB
Susceptible,
Resistant,
Intermediate, Not
tested)

Antimicrobial
Susceptibility Test
Method

Gene Identifier

Antimicrobial
PHVS_Susceptibility P
Susceptibility Test TestMethod_TB
Method (e.g. ETest, MIC, Disk
Diffusion)
Gene identifier PHVS_GeneName_T P
Please report the B
full test results for
the samples that
have unique
features, such as
specimen type
(sputum or another
anatomic site), test
type (sequencing or
non-sequencing) or
mutation (detected
or not detected).
There is no need to
report test results
that differ only by
date or laboratory
and where all other
aspects are
identical in regards
to specimen type,
test type, and/or
the results of
mutation.

Molecular Susceptibility Molecular
Specimen Collection
Susceptibility
Date
Specimen
Collection Date
Molecular Susceptibility Molecular
Date Reported
Susceptibility Date
Reported
Molecular Susceptibility Molecular
Specimen Type
Susceptibility
Specimen Type
Molecular Susceptibility Molecular
Test Result
Susceptibility Test
Result
Molecular Susceptibility Molecular
Susceptibility
Nucleic Acid Change
Nucleic Acid
Change

N/A

P

N/A

P

PHVS_MicroscopicE P
xamCultureSite_TB
PHVS_MolecularTes P
tResults_TB
N/A

P

Molecular Susceptibility Molecular
N/A
Amino Acid Change
Susceptibility
Amino Acid Change

P

Molecular Susceptibility Molecular
PHVS_MolecularInd P
Indel
Susceptibility Indel el_TB
Molecular Susceptibility Molecular
PHVS_MolecularTes P
Susceptibility Test tMethods_TB
Test Method
Method
Culture Conversion
PHVS_YesNoUnkno P
Did the patient's
Documented
wn_CDC
sputum become
culture negative?
Date of First
Date the first
N/A
P
Consistently Negative consistently
Culture
negative sputum
culture was
collected.
Indicate the one
Reason for Not
PHVS_SputumCultur P
Documenting Sputum reason for not
eConversionNotDoc
documenting the umentedReason_TB
Culture Conversion
sputum culture
conversion.
Patient Move During TB Did the patient
PHVS_YesNoUnkno P
move during
Therapy
wn_CDC
therapy?
Moved to Where
If the patient
PHVS_MovedWhere P
moved to a
DuringTherapy_TB
different reporting
area during TB
therapy, select all
that apply to where
the patient moved.
Out of State Move

Out of Country Move

Transnational Referral

If moved out of
PHVS_State_FIPS_5- P
state, then specify 2
the new state
jurisdiction.
If moved out of
PHVS_Country_ISO_ P
country, then
3166-1
specify the new
country
jurisdiction.
If moved out of the PHVS_YesNoUnkno P
US, indicate
wn_CDC
whether a
transnational
referral was made.

History of Treatment

Date MDR Treatment
Started

History of
PHVS_YesNoUnkno P
treatment before wn_CDC
current episode
with second-line TB
drugs for the
treatment of TB
disease (not LTBI)
Date MDR TB
N/A
P
therapy started for
current episode

Drug Used to Treat
MDR TB

Drugs ever used for PHVS_Medications_ P
MDR TB treatment, TB
from MDR start
date: Please
provide a response
for each
medication in the
value set with an
associated
indicator.
Medications should
be recorded as part
of the regimen
beginning with the
MDR TB therapy
start date.

Length of Time Drug
Was Administered

Indicate length of
time drug was
taken or if it was
not taken
Date injectable
medication
stopped. If no
injectable drugs
were used leave
blank.
Surgery to Treat
MDR TB
Surgery to Treat
MDR TB Date

Date Injectable
Medication Stopped

Surgery to Treat MDR
TB
Surgery to Treat MDR
TB Date

PHVS_LengthofTime P
DrugTaken_TB

N/A

P

PHVS_YesNoUnkno P
wn_CDC
N/A
P

Adverse Event
Description

Did patient
PHVS_SideEffectofTr P
experience any of eatment_TB
the following side
effects during
treatment that
resulted in a
permanent
discontinuation of
medication or at
the end of
treatment were
there any of the
following side
effects related to
MDR-TB treatment
present? Please
provide a response
for all side effects
in the value set
with an associated
indicator.

Adverse Event Indicator Side Effects of
PHVS_YesNoUnkno P
Treatment
wn_CDC
Indicator
Adverse Event
Did the side effect PHVS_SideEffectTim P
Manifestation Time
manifest during
etoOnset_TB
treatment or at the
end of treatment?
Usual Occupation and
Industry
Meets Binational
Reporting Criteria

Usual occupation TBD
P
and industry
Does case meet
PHVS_YesNoUnkno P
binational reporting wn_CDC
criteria?
Patient Treated as MDR Was the Patient
PHVS_YesNoUnkno P
Case
Treated as an MDR wn_CDC
TB Case (Regardless
of DST Results?

Label/Short Name
Immuncompromised
Date first medical
Fever/sweats/chills
Confusion/delirium

Vomiting/diarrhea/abdominal pain
Sore throat
Cough
Chest Pain
Shortness of breath
Other_symptoms
Other_symptoms_specify
Lymphadenopathy
Describe lympadenopathy
Skin lesions
Describe skin lesions
Conjunctivitis
Pharyngitis/tonsilitis
Chest X-ray
Antibiotic
Antibiotic start date
Illness outcome
Primary clinical syndrome
F. tularensis cultured
Specimen source
Date specimen collected
F. tularensis detected
Test performed
Specimen source

Description
If patient has any immunocompromising
conditions, specify
Date that the patient was first seen by medical
person.
Did the patient's illness include the symptom
of fever/sweats/chills?
Did the patient's illness include the symptom
of confusion/delirium?
Did the patient's illness include the symptom
of vomiting/diarrhea/abdominal pain?
Did the patient's illness include the symptom
of sore throat?
Did the patient's illness include the symptom
of cough?
Did the patient's illness include the symptom
of chest pain?
Did the patient's illness include the symptom
of shortness of breath?
Did the patient's illness include other
symptoms of not listed?
Which other symptoms did the patient's illness
include?
Did the patient have lymphadenopathy?
If lymphadenopathy present, provide location
and description.
Did the patient have skin lesion?
If skin lesion present, provide location and
description.
Did the patient have conjunctivitis?
Did the patient have pharyngitis/tonsilitis?
Results of chest x-ray
Did patient receive an effective antibiotic for
illness?
Date each antibiotic started
Outcome of illness
Classification of primary clinical manifestation
of infection
Was F. tularensis cultured?
Source of culture
Date specimen was collected
Was F. tularensis detected by other tests?
Test used to detect F. tularensis
Specimen source in which F. tularenisis was
detected

Date specimen collected
F. tularensis subspecies
Serology
First Serum titer
Second Serum titer
Date first serum drawn
Date second serum drawn
Epi-linked to other cases
Epi-link specify
Travel associated
Travel specify
Animal contact

Date of specimen collection
Subspecies of F. tularensis detected
Serology results
Titer results
Titer results
Date first serum drawn
Date second serum drawn
Was this illness epi-linked to any other
tularemia cases?
Describe epi-linked case
Was this illness associated with travel?
Describe travel
Did patient have any animal contact in the 2
weeks preceding illness?

Indicate if domestic animal contact occurred
and specify domestic animals that patient had
Domestic animal
contact with in the 2 weeks preceding illness
Type of animal contact
Was animal domestic or wild
Indicate if wild animal contact occurred and
specify wild animals that patient had contact
Wild animal
with in the 2 weeks preceding illness
Nature of contact
Nature of animal contact
Did patient have tick or deerfly bite in the two
Tick or deerfly bite
weeks preceding illness?
Did patient have contact with or ingestion of
Contact with or ingestion of untreated untreated water in the two weeks preceding
illness?
water
Did patient participate in any environmental
aerosol generating activities in the two weeks
Environmental aerosol generating
preceding illness
activities
Specify environmental aerosol
Specify environmental aerosol generating
generating activities
activities
Specify any other exposures in the two weeks
Other exposure
preceding illness
Comments
Additional comments

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

P

N/A
PHVS_YesNoUnknown_CDC

P

PHVS_YesNoUnknown_CDC

P
P

PHVS_YesNoUnknown_CDC
P
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC

P
P
P
P

PHVS_YesNoUnknown_CDC

P

N/A
PHVS_YesNoUnknown_CDC
N/A

P
P

PHVS_YesNoUnknown_CDC
N/A
PHVS_YesNoUnknown_CDC
PHVS_YesNoUnknown_CDC
TBD
TBD
N/A
TBD
TBD

P
P
P
P
P
P
P
P
P

PHVS_YesNoUnknown_CDC
N/A
N/A
PHVS_YesNoUnknown_CDC
N/A

P
P
P
P
P
P

N/A

P

N/A
TBD
TBD
N/A
N/A
N/A
N/A

P
P
P
P
P
P
P

PHVS_YesNoUnknown_CDC
N/A
PHVS_YesNoUnknown_CDC
N/A

P
P
P
P

PHVS_YesNoUnknown_CDC

P

N/A
TBD

P
P

N/A
TBD
TBD

P
P

PHVS_YesNoUnknown_CDC

P

PHVS_YesNoUnknown_CDC

P

N/A

P

N/A
N/A

P
P

P

Label/Short Name

Description

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.
PHVS_VaccineNotGivenReasons_CDC
If the value in Did the patient receive varicella-containing vaccine? is No, choose the
reason why the patient did not receive the vaccine; if none of the specific choices in
the list apply, choose Other.
Other reason why patient did not
If the value specified in Reason why patient did not receive varicella-containing vaccine
receive Varicella-containing vaccine is Other, indicate the reason (a reason other than those provided in the list).
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

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)
Location First Noted
If a value of Generalized is specified for the Rash Location field, choose location where PHVS_RashLocationFirstNoted_VZ
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)
Macules Present
PHVS_YesNoUnknown_CDC
If the value specified in Total Number of Lesions is < 50, indicate whether macules
were present.
If the value specified in Macules Present is Yes, indicate how many macules were
Number of Macules
present.
If the value specified in Total Number of Lesions is < 50, indicate whether papules were PHVS_YesNoUnknown_CDC
Papules Present
present.
Number of Papules
If the value specified in Papules Present is Yes, indicate how many papules were present.
Vesicles Present
Number of Vesicles

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 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
Fever Onset Date
If the value specified in Did patient have fever? is Yes, indicate the date when the fever
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
If the value specified in Did patient have fever? is Yes, indicate the number of days for
Fever Duration in Days
which the patient had a fever.
PHVS_YesNoUnknown_CDC
Is patient immunocompromised due Indicate whether the patient was immunocompromised (anergic).
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
Indicate whether the patient visited a healthcare provider during the course of this
PHVS_YesNoUnknown_CDC
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