Form CDC 52.15A REV.8-2 CDC 52.15A REV.8-2 ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs) INVASIVE PNEUM

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:

Date of positive culture __ __ / __ __ / __ __ __ __ Date form completed __ __ / __ __ / __ __ __ __ OMB No. 0920-0978

What sources had case
vaccination history available?

Medical Chart

1 ☐ Yes

2 ☐ No

9 ☐ Did not check

Primary Care Provider

1 ☐ Yes

2 ☐ No

9 ☐ Did not check

Vaccine Registry

1 ☐ Yes

2 ☐ No

9 ☐ Did not check

Other

1 ☐ Yes

2 ☐ No

9 ☐ Did not check

☐ Case has never received vaccines

☐ Vaccination history unknown

Pneumococcal Vaccines for All Ages (Additional products will be listed in the database as FDA authorization received)
Vaccines
Pneumococcal
conjugate vaccine

Dose #
1

Dates of immunizations

Manufacturer

Vaccine name

__ __ / __ __ / __ __ __ __
Month Day
Year

☐ Merck
☐ Wyeth/Pfizer
☐ Other _________
☐ Unknown

☐ Medical Chart
☐ Registry
☐ Primary Care Provider
☐ Other

☐ Merck
☐ Other _________
☐ Unknown

☐ Prevnar™ (PCV7)
☐ Prevnar 13™ (PCV13)
☐ Vaxneuvance™ (PCV15)
☐ Prevnar 20™ (PCV20)
☐ Other _________
☐ Unknown
☐ Prevnar™ (PCV7)
☐ Prevnar 13™ (PCV13)
☐ Vaxneuvance™ (PCV15)
☐ Prevnar 20™ (PCV20)
☐ Other _________
☐ Unknown
☐ Prevnar™ (PCV7)
☐ Prevnar 13™ (PCV13)
☐ Vaxneuvance™ (PCV15)
☐ Prevnar 20™ (PCV20)
☐ Other _________
☐ Unknown
☐ Prevnar™ (PCV7)
☐ Prevnar 13™ (PCV13)
☐ Vaxneuvance™ (PCV15)
☐ Prevnar 20™ (PCV20)
☐ Other _________
☐ Unknown
☐ Prevnar™ (PCV7)
☐ Prevnar 13™ (PCV13)
☐ Vaxneuvance™ (PCV15)
☐ Prevnar 20™ (PCV20)
☐ Other _________
☐ Unknown
☐ Prevnar™ (PCV7)
☐ Prevnar 13™ (PCV13)
☐ Vaxneuvance™ (PCV15)
☐ Prevnar 20™ (PCV20)
☐ Other _________
☐ Unknown
☐ Pneumovax™ 23 (PPSV23/PPV23)
☐ Other _________
☐ Unknown

☐ Merck
☐ Other _________
☐ Unknown

☐ Pneumovax™ 23 (PPSV23/PPV23)
☐ Other _________
☐ Unknown

☐ Medical Chart
☐ Registry
☐ Primary Care Provider
☐ Other

☐ Unknown date

2

__ __ / __ __ / __ __ __ __
Month Day
Year
☐ Unknown date

3

__ __ / __ __ / __ __ __ __
Month Day
Year
☐ Unknown date

4

__ __ / __ __ / __ __ __ __
Month Day
Year
☐ Unknown date

5

__ __ / __ __ / __ __ __ __
Month Day
Year
☐ Unknown date

6

__ __ / __ __ / __ __ __ __
Month Day
Year
☐ Unknown date

Pneumococcal
polysaccharide
vaccine

1

__ __ / __ __ / __ __ __ __
Month Day
Year

☐ Merck
☐ Wyeth/Pfizer
☐ Other _________
☐ Unknown

☐ Merck
☐ Wyeth/Pfizer
☐ Other _________
☐ Unknown

☐ Merck
☐ Wyeth/Pfizer
☐ Other _________
☐ Unknown

☐ Merck
☐ Wyeth/Pfizer
☐ Other _________
☐ Unknown

☐ Merck
☐ Wyeth/Pfizer
☐ Other _________
☐ Unknown

☐ Unknown date
2

__ __ / __ __ / __ __ __ __
Month Day
Year
☐ Unknown date

Lot #

Dose 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

- IMPORTANT – PLEASE COMPELETE THE BACK OF THIS FORM 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 Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA(0920-0978). Do not send the completed form to this address.
Page 1 of 2

CDC 52.15A REV. 8-2023

Additional Vaccines and Related Agents for Certain Age Groups
Complete for children ≥2 months to <5 years only:
Vaccines and related agents
Diphtheria/Tetanus/ Pertussis (DTP or DTaP)*

Haemophilus influenzae type B (Hib)*

Dose #

Dates of immunizations

1

__ __ / __ __ / __ __ __ __
Month Day
Year

☐ Unknown date

2

__ __ / __ __ / __ __ __ __
Month Day
Year

☐ Unknown date

3

__ __ / __ __ / __ __ __ __
Month Day
Year

☐ Unknown date

4

__ __ / __ __ / __ __ __ __
Month Day
Year

☐ Unknown date

5

__ __ / __ __ / __ __ __ __
Month Day
Year

☐ Unknown date

1

__ __ / __ __ / __ __ __ __
Month Day
Year

☐ Unknown date

2

__ __ / __ __ / __ __ __ __
Month Day
Year

☐ Unknown date

3

__ __ / __ __ / __ __ __ __
Month Day
Year

☐ Unknown date

4

__ __ / __ __ / __ __ __ __
Month Day
Year

☐ Unknown date

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

Person completing the form (please print):
Title:__________________

Phone: (

) ______________

Fax: (

) ______________

Please return form to: __________________________________________________

Phone: (

) ______________

Fax: (

) ______________

Name: _________________________________

Page 2 of 2

CDC 52.15A REV. 8-2023