Form no number no number ABCs Invasive Pneumococcal Disease in Children Form

Active Bacterial Core Surveillance (ABCs)

Attachment 5_SPN_CRFexpanded_final ABCS Invasive Pneumo in Children Case ReportForm11 28 07recd041008

ABCs Invasive Pneumococcal Disease in Children Case Report Form

OMB: 0920-0802

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Patient’s Name __________________ Patient’s Date of Birth ___/__/____

ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs)

INVASIVE PNEUMOCOCCAL DISEASE IN CHILDREN

Revised 10/24/2003


StateID: __ __ __ __ __ __ __

Date of positive culture ____/____/_____ Date form completed ____/____/_____

- VACCINE HISTORY -




  • Child has never received vaccines

  • Vaccination history unknown


VACCINES

Dose #

Dates of immunizations

Manufacturer

Vaccine name

Lot #

Pneumococcal conjugate vaccine (Prevnar®)

1





2





3





4





Pneumococcal polysaccharide vaccine (Pneumovax® 23)

1





2







Diphtheria/Tetanus/

Pertussis (DTP or DtaP)

1





2





3





4





5







Haemophilus influenza type B (Hib)

1





2





3





4





Influenza vaccine


1





2




3




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


- IMMUNE SYSTEM EVALUATION-




Does this patient have an immune disorder other than HIV or AIDS? □ Yes □ No □ Unknown

If yes, diagnosis _________________________

If yes, indicate below results for any tests performed to evaluate immune function:

Tests Test Date Result

IgGtotal..……………___/___/_____ □ Low □ Normal □ High □ Not done

IgG1…………………___/___/_____ □ Low □ Normal □ High □ Not done

IgG2…………………___/___/_____ □ Low □ Normal □ High □ Not done

IgG3…………………___/___/_____ □ Low □ Normal □ High □ Not done

IgG4…………………___/___/_____ □ Low □ Normal □ High □ Not done

IgM………………….___/___/_____ □ Low □ Normal □ High □ Not done

IgA…………………..___/___/_____ □ Low □ Normal □ High □ Not done C3……………………___/___/_____ □ Low □ Normal □ High □ Not done

C4……………………___/___/_____ □ Low □ Normal □ High □ Not done

CH50………………...___/___/_____ □ Low □ Normal □ High □ Not done

Other (specify_____________)___/___/_____ □ Low □ Normal □ High □ Not done

Other (specify_____________)___/___/_____ □ Low □ Normal □ High □ Not done

Person completing the form (please print): Phone: ( )______________

Name ___________________Title ___________ Fax: ( )______________


Please return ______________________ Phone: ( )______________

form to: ______________________ Fax: ( )______________

______________________

File Typeapplication/msword
File TitlePNEUMOCOCCAL CONJUGATE VACCINE EFFECTIVENESS STUDY
Authortdp4
Last Modified Bylhl4
File Modified2008-04-11
File Created2008-04-11

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