Form No number No number Typhoid Fever Surveillance

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES
Public Health Service
Centers for Disease Control
and Prevention (CDC)
Atlanta, Georgia 30333

TYPHOID FEVER SURVEILLANCE REPORT

CDC NO.:

Instructions:

(1-5)

– Please complete this form only for new, symptomatic, culture-proven cases of typhoid fever. –

Form Approved OMB No. 0920-0009

DEMOGRAPHIC DATA
1. Reporting

2. First three letters of

State:

3. Date

patient’s last name:

(6-7)

of birth:

(8-10)

Mo.

4. Sex: (19)
1

5. Does the patient work as a foodhandler?(20)

■ Male ■ Female
2

1

Day

(17-18)

Yr.

6. Citizenship: (21)

■ Yes ■ No ■ Unk.
0

or Age:
(in years)

(11-16)

9

1

■ U.S. ■ Other: __________________________________________ ■ Unk.
8

9

CLINICAL DATA
7. Was the patient ill with typhoid

1

■

Yes

0

■

No

9

■

8. Was the patient

If Yes, give date of
onset of symptoms:

fever? (fever, abdominal pain,
headache, etc) (22)

If Yes, how many days was
the patient hospitalized?

hospitalized?(29)

9. Outcome of case: (32)
1

Unk.

1

(23-28)
Mo.

Day

Yr.

■

Yes

0

■

No

9

■

Unk.

9

(30-31)
Days

■ Recovered ■ Died
■ Unk.
2

LABORATORY DATA
10. Date Salmonella typhi first isolated:

Site(s) of isolation:
(check all that apply)
1

(33-38)
Mo.

Day

Yr.

■ Blood ■ Stool ■ Gall bladder ■ Other (specify): ________________________________________
2

on this (these) isolate(s) at the laboratory?
(Please contact the clinical laboratory for
this information) (56)

■ Yes ■ No ■ Unk.
0

3

8

(40-55)

11. Was antibiotic sensitivity testing performed

1

(39)

If Yes, was
the organism
resistant to:

9

{

• Ampicillin: ..........................................................(57) 1
• Chloramphenicol: ..............................................(58) 1
• Trimethoprim-sulfamethoxazole: .......................(59) 1
• Fluoroquinolones (e.g., Ciprofloxacin):..............(60) 1

■ Yes
■ Yes
■ Yes
■ Yes

0
0
0
0

■ No
■ No
■ No
■ No

9
9
9
9

■ Not tested
■ Not tested
■ Not tested
■ Not tested

EPIDEMIOLOGIC DATA
12. Did this case occur as part of an outbreak?
(two or more cases of typhoid fever associated by time and place) (61) 1

■ Yes ■ No ■ Unk.
0

9

Year received:

13. Did the patient receive typhoid vaccination
(primary series or booster) within
five years before onset of illness?(62)
1

■ Yes ■ No ■ Unk.
0

9

14. Did the patient travel or live outside
the United States during the 30 days
before the illness began?(72)
1

If Yes,
indicate type
of vaccine
received:

■ Yes ■ No ■ Unk.
0

9

{

• Standard killed typhoid shot (Wyeth-Ayerst): ....(63) 1
• Oral Ty21a or Vivotif (Berna) four pill series:.....(66) 1
• ViCPS or Typhim Vi shot (Pasteur Merieux): ....(69) 1

■ Yes ■ No ■ Unk.
■ Yes ■ No ■ Unk.
■ Yes ■ No ■ Unk.

If Yes, please list in order the countries visited during the 30 days
before the illness began: (other than the United States)
1.

c.) Visiting relatives or friends? ...............(145) 1
16. Was the case
traced to a typhoid carrier? ......................(165) 1

0

9

(67-68)

0

9

(70-71)

(105-120)

4.
(89-104)

b.) Tourism? ............................................(144) 1

(64-65)

3.

2.

a.) Business? ..........................................(143) 1

9

Date of most recent return or
entry to the United States:

(73-88)

15. Was the purpose of the international travel:

0

■ Yes ■ No ■ Unk.
■ Yes ■ No ■ Unk.
■ Yes ■ No ■ Unk.
0

9

d.) Immigration to U.S.? .............(146) 1

0

9

e.) Other?...................................(147) 1

0

9

■ Yes ■ No ■ Unk.
0

9

Mo.

(121-136)

Day

Yr.

(137-142)

■ Yes ■ No ■ Unk.
■ Yes ■ No ■ Unk.
0

9

0

9

(if other, specify): _________________________________________________
(148-164)

If Yes, was the carrier previously
known to the health department?..... 1
(166)

■ Yes ■ No ■ Unk.
0

9

17. Comments:

18.

Name of Person
Completing Form: _____________________________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________________________
Telephone: ( _________ ) __________________________________

Date: _______/ _______/ _______
Mo.

Day

Yr.

– THANK YOU VERY MUCH FOR TAKING THE TIME TO COMPLETE THIS FORM –

Please send a copy to your S TATE E PIDEMIOLOGY O FFICE and the
F OODBORNE AND D IARRHEAL D ISEASES B RANCH , C ENTERS FOR D ISEASE C ONTROL
Mailstop A-38, Atlanta, Georgia, 30333.
•
Fax: (404) 639-2205

AND

P REVENTION ,

Public reporting burden of this collection of information is estimated to average 20 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 of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0009).
CDC 52.5 6/97

TYPHOID FEVER SURVEILLANCE REPORT

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