New Jersey Department of Health

Vaccine Preventable Disease Program

PO Box 369

Trenton, NJ 08625-0369

MENINGOCOCCAL DISEASE CASE REPORT	Report Status

Confirmed Probable Not a Case
CDRSS#

E#

REPORTING INFORMATION
Reported By

Date Reported to LHD/State

_ _ / _ _ / _ _ _ _	Telephone No.

( _ _ _ ) _ _ _ - _ _ _ _
Reporting Site/Clinic

Town/City

County

Type of Reporting Site

College/University	Healthcare Provider	Correctional Facility

School/Day Care	Health Department	Other:
PATIENT INFORMATION
Patient Name (Last, First)

Date of Birth

_ _ / _ _ / _ _ _ _	Age

Address

Telephone Number

( _ _ _ ) _ _ _ - _ _ _ _	Secondary Telephone Number

( _ _ _ ) _ _ _ - _ _ _ _
City

Zip Code

County

Race

White	Asian/Pacific Islander

Black	Alaskan/Native American

Unknown	Other:	Ethnicity

Hispanic

Non-Hispanic

Unknown	Sex

Male

Female
Alternate Address (If applicable, e.g., school, dormitory)

Telephone Number

( _ _ _ ) _ _ _ - _ _ _ _
City

State

Zip Code

County

Emergency Contact (Last, First)

Telephone Number

( _ _ _ ) _ _ _ - _ _ _ _
Relationship

Parent/Guardian Spouse Sibling Other (specify):
CLINICAL INFORMATION
Illness Onset Date

_ _ / _ _ / _ _ _ _	Date of Initial Healthcare Evaluation

_ _ / _ _ / _ _ _ _
Medical Facility

Telephone Number

( _ _ _ ) _ _ _ - _ _ _ _
Treating Physician

Telephone Number

( _ _ _ ) _ _ _ - _ _ _ _
Primary Care Physician

Telephone Number

( _ _ _ ) _ _ _ - _ _ _ _
Symptoms

Altered Mental Status	Fever (highest recorded: )	Nausea	Shock

Chills	Headache	Petechial Rash	Stiff Neck

Coma	Malaise	Photophobia	Vascular Disease

Fatigue	Meningitis	Purpuric Rash	Vomiting

Other:

CLINICAL INFORMATION, CONTINUED
Admission Date:	_ _ / _ _ / _ _ _ _

Discharge Date:	_ _ / _ _ / _ _ _ _

Was Patient Admitted through ED?	Yes No

Was Patient Admitted to ICU?	Yes No

Was Patient on a Mechanical Ventilator?	Yes No

Is Patient Deceased?	Yes No

If Yes, Date of Death:	_ _ / _ _ / _ _ _ _	Medical Record Number:

Treatment

Medication: __________________________ Dose:

Date(s): _ _ / _ _ / _ _ _ _ - _ _ / _ _ / _ _ _ _

Medication: __________________________ Dose:

Date(s): _ _ / _ _ / _ _ _ _ - _ _ / _ _ / _ _ _ _

Medication: __________________________ Dose:

Date(s): _ _ / _ _ / _ _ _ _ - _ _ / _ _ / _ _ _ _
Is Patient Pregnant?

Yes No Unknown	If Yes, Estimated Delivery Date: _ _ / _ _ / _ _ _ _
Risk Factors

Active or Passive Smoking

Recent Respiratory Illness

Underlying Condition/Immunosuppressed (specify):

Known Exposure to Other Case

Lives in College Dorm/Military Barracks

Recent Travel

Other (specify):	Previous History of Vaccination?

Yes No Unknown

If Yes:

MCV4 MPSV4 Other (specify):

Date of First Dose: _ _ / _ _ / _ _ _ _

Brand:

Date of Second Dose: _ _ / _ _ / _ _ _ _

Brand:
Is Patient part of a Cluster/Outbreak?

Yes (Name of Outbreak): ____________________	No Unknown

Is Patient a Known MSM?

Yes No Unknown
LABORATORY INFORMATION
Date of Blood Specimen Collection: _ _ / _ _ / _ _ _ _

Gram Stain: Gram-negative Diplococci No Organism

Culture Result: N. meningitidis No Growth

Was Specimen Collected Prior to Treatment?

Yes No Unknown	Date of CSF Specimen Collection: _ _ / _ _ / _ _ _ _

Gram Stain: Gram-negative Diplococci No Organism

Culture Result: N. meningitidis No Growth

Was Specimen Collected Prior to Treatment?

Yes No Unknown
CSF Characteristics	Serum Characteristics
Color/Clarity:	N/A
Pressure:	N/A
Protein:	N/A
Glucose:
RBC Count:
WBC Count:
Predominate Cell Type:
Other Laboratory Test (specify): ____________________ Result: ____________________

Collection Date: _ _ / _ _ / _ _ _ _	Was Specimen Collected Prior to Treatment?

Specimen: ____________________	Yes No Unknown

ADDITIONAL COMMENTS

MENINGOCOCCAL DISEASE CASE REPORT

Contact Follow-Up

Record information of close contacts below. All household members (including roommates), and any person who may have had contact with oral secretions should be included.

Name of Contact	Nature of Contact*

(List # of all that apply)	Date(s) of Exposure	Date of Birth	Sex	Phone	Previous Immunization?

(Provide dates if known)	Recommended

Prophylaxis?

(Y/N)	Taken

Prophylaxis

(Y/N/Unknown)?	Prophylaxis

Type(s) and Dates
*Nature of Contact:

(1) Household (includes roommates in dormitories)

(2) Intimate contact (including kissing)

(3) Shared food, drink, cigarettes, lipstick, or any articles put in/on mouth

(4) Overnight stay

(5) Preschool/Day Care (younger than kindergarten)

(6) Healthcare/EMS worker exposed to patient’s oral/nasal secretions through unprotected mouth-to-mouth resuscitation, intubation, or suctioning

(7) Other (explain)

MENINGOCOCCAL DISEASE CASE REPORT

(Continued)

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imm-23 mENINGOCOCCAL dISEASE cASE rEPORT

EWHITE

2014-09-19

NJDOH