Form 0920-0978 2 months to

Patient’s Name

Patient’s Date of Birth

/

/

– Patient identifier information is not transmitted to CDC –

ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs) INVASIVE PNEUMOCOCCAL
DISEASE IN CHILDREN (aged ≥2 months to <5 years) AND ADULTS (aged ≥ 65 years)
StateID:

What sources had
case vaccination
history available?

Date of positive culture

/

/

Medical Chart

Primary Care Provider

Vaccine Registry

Other

VACCINES

Pneumococcal
conjugate vaccine

Dose #

Dates of immunizations

Date form completed
Response Codes:
1 = Yes
2 = No
9 = Did not check

Manufacturer

/

/

OMB No. 0920-0978

Case has never received vaccines
Vaccination history unknown

Vaccine name

Lot #

1

Dose #1 source:

Medical Chart

Registry

Primary Care Provider

Other

Medical Chart

Registry

Primary Care Provider

Other

Medical Chart

Registry

Primary Care Provider

Other

Medical Chart

Registry

Primary Care Provider

Other

Medical Chart

Registry

Primary Care Provider

Other

Medical Chart

Registry

Primary Care Provider

Other

Medical Chart

Registry

Primary Care Provider

Other

Medical Chart

Registry

Primary Care Provider

Other

2

Dose #2 source:
3

Dose #3 source:
4

Dose #4 source:
5

Dose #5 source:
6

Dose #6 source:

Pneumococcal
polysaccharide vaccine

1

Dose #1 source:
2

Dose #2 source:

**Only complete vaccination information on DTP or DTap and Hib
vaccination for children aged ≥2 months to <5 years**

Diphtheria/Tetanus/
Pertussis (DTP or DTaP)

1

**Only complete healthcare provider source information for
children aged ≥2 months to <5 years**

2

Health Care Provider Information

3

Was health care provider information available from the
following sources?

4
5

Haemophilus influenzae
type B (Hib)

Medical Chart:

1
2
3

Did Not Check

Vaccine Registry:

Did Not Check

Parent/Guardian:

Did Not Check

Refused

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

4

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

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

Title

Phone: (

)

Phone: (

)

Fax:
Fax:

(
(

)
)

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless
it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden to CDC,
CDC/ATSDR Reports Clearance Oflcer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA(0920-0978). Do not send the completed form to this address.
CDC 52.15A REV. 8-2018