Professional Documents
Culture Documents
EpiSurv No.
Disease Name
Measles
Mumps
Rubella
Reporting Authority
Name of Public Health Officer responsible for case
Notifier Identification
Reporting source*
General Practitioner
Hospital-based Practitioner
Laboratory
Self-notification
Outbreak Investigation
Other
Organisation
Date reported*
Contact phone
Usual GP
GP phone
Practice
GP/Practice address
Number
Street
Suburb
Town/City
Post Code
GeoCode
Case Identification
Name of case*
Surname
Given Name(s)
NHI number*
Current address*
Email
Number
Street
Suburb
Town/City
Post Code
Phone (home)
Phone (work)
GeoCode
Phone (other)
Case Demography
Location
TA*
DHB*
Date of birth*
Sex*
OR
Male
Female
Age
Days
Indeterminate
Months
Years
Unknown
Occupation*
Occupation location
Place of Work
School
Pre-school
Name
Address
Number
Street
Suburb
Town/City
Alternative location
Post Code
Place of Work
School
GeoCode
Pre-school
Name
Address
Number
Street
Suburb
Town/City
Post Code
GeoCode
Maori
Samoan
Niuean
Chinese
Indian
Tongan
*(specify)
Page 1 of 4
EpiSurv No.
Basis of Diagnosis
CLINICAL CRITERIA
Fits Clinical Description*
Measles
Yes
No
Unknown
Yes
No
Unknown
Maculopapular rash
Yes
No
Unknown
Cough
Yes
No
Unknown
Coryza
Yes
No
Unknown
Conjunctivitis
Yes
No
Unknown
Koplik's spots
Yes
No
Unknown
Fever
Yes
No
Unknown
Yes
No
Unknown
Orchitis
Yes
No
Unknown
Fever
Yes
No
Unknown
Maculopapular rash
Yes
No
Unknown
Arthritis/arthralgia
Yes
No
Unknown
Lymphadenopathy
Yes
No
Unknown
Conjunctivitis
Yes
No
Unknown
Mumps
Rubella
LABORATORY CRITERIA
Laboratory confirmation of disease*
Yes
No
Not Done
Awaiting Results
Confirmation method
Isolation of virus from clinical specimen
EPIDEMIOLOGICAL CRITERIA
Contact with a confirmed case*
Yes
No
Unknown
CLASSIFICATION*
Under investigation
Probable
Confirmed
Not a case
Yes
Date hospitalised*
Approximate
Unknown
No
Unknown
Unknown
Hospital*
Died*
Yes
No
Date died*
Was this disease the primary cause of death?*
Unknown
Unknown
Yes
No
Unknown
Page 2 of 4
EpiSurv No.
Outbreak Details
Is this case part of an outbreak (i.e. known to be linked to one or more other cases of the same disease)?*
If yes, specify Outbreak No.*
Yes
Risk Factors
Contact with another case of the disease during the incubation period for
this disease*
Yes
No
Unknown
Yes
No
Unknown
Was the case overseas during the incubation period for this disease?*
Yes
No
Unknown
Date Entered*
Date Departed*
Last*
Second Last*
Third Last*
Other risk factors for measles, mumps or rubella (specify)*
Imported
Import-related
Endemic
Unknown
Protective Factors
At any time prior to onset, had the case been immunised with the MMR or
appropriate monovalent vaccine?*
If yes specify, vaccine details*
First administered dose:*
Date given*
MMR/Monovalent
Weeks
Patient/caregiver recall
Unknown
MMR/Monovalent
Months
Years
Months
Years
Documented
Not given
Source of information*
No
Unknown
Source of information*
Date given*
Yes
Unknown
Weeks
Patient/caregiver recall
Documented
Management
CASE MANAGEMENT
Date case investigation was started*
(measles and rubella only)
Yes
No
NA
Yes
No
Unknown
Unknown
Page 3 of 4
EpiSurv No.
Management
CONTACT MANAGEMENT
Did the case have any contacts (measles and rubella only)?*
Yes
No
Unknown
Category
Number
susceptible
Number given
MMR
(measles only)
Number
Number given
declined MMR
IG
(measles only) (measles only)
Flight number(s)
Date of departure
Unimmunised susceptibles excluded from school/pre-school/
childcare for appropriate period*
Yes
No
NA
Unknown
Comments*
Page 4 of 4