Free F-44236 - Wisconsin


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http://dhs.wisconsin.gov/forms/dph/DPH04236.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Public Health DPH 4236 (Rev. 05/04)

STATE OF WISCONSIN s.252.05, Wis. Stats. (608) 266-2346

PERTUSSIS CASE REPORT

This form has been renumbered and revised. Please update your link with the following: http://dhs.wisconsin.gov/forms/F4/F44236.pdf

DPH 4236 (Rev. 05/04) Page 2 of 4

Name of case ________________________________ Complete Only for Children Ages <15 Years

Vaccinated with DTP or DTaP Vaccine? Yes No Vaccination Date Type Vaccine Type Codes 1. VACCINE HISTORY 2. 3. 4. 5. 6. _____________ ______________ ______________ ______________ ______________ ______________ 1. _____ 2. _____ 3. _____ 4. _____ 5. _____ 6. _____ W = DTP Whole Cell A = DTaP D = DT or Td T = DTaP/Hib P = Pertussis only O = Other U = Unknown Reason not vaccinated with > 3 doses of pertussis vaccine:

Unknown Manufacturer 1. _________ 2. _________ 3. _________ 4. _________ 5. _________ 6. _________

Manufacturer Codes C = Connaught (Aventis) L = Lederle (N/A) S = SmithKline, Glaxo N = North American M = Massachusetts HD I = Michigan HD O = Other U = Unknown

Note: Record type and manufacturer codes for children 2 months through 6 years of age.

1. Religious exemption 2. Medical contraindication 3. Philosophical exemption

4. Previous pertussis confirmed 5. Parental refusal 6. Age <7 months

7. Other 9. Unknown

Were antibiotics given? First antibiotic received:

Yes

No

Unknown Check () One 1. Erythromycin ( includes Pediazole, ilosone) recommended 2. Trimethoprin-Sufamethoxazole ((bactrim/septra, TMP-SMZ) recommended 3. Clarithromycin/azithromycin recommended 4. Tetracycline/Doxycycline 5. Amoxicillin/Penicillin/Ampicillin/Augmentin/Ceclor/Cefixime 6. Other ____________________________ 9. Unknown Check () One 1. Erythromycin ( includes Pediazole, ilosone) recommended 2. Trimethoprin-Sufamethoxazole (bactrim/septra, TMP-SMZ)) recommended 3. Clarithromycin/azithromycin recommended 4. Tetracycline/Doxycycline 5. Amoxicillin/Penicillin/Ampicillin/Augmentin/Ceclor/Cefixime 6. Other ____________________________ 9. Unknown

Date started: _____________________ TREATMENT Number of days taken: _____________

Second antibiotic received: Date started: _____________________ Number of days taken: _____________

Possible SOURCE for this Case (for LHD use) Name Age Address Telephone Number Name of School, Daycare, Employer Cough Onset Date

SOURCE What is the Source Setting(s) of this Case? 1 Daycare 2 School Work 3 Doctor's Office 4 Hospital Ward 5 Hospital ER

6 Hospital Outpatient Clinic 7 Home 8 Work 9 Unknown 10 College

11 Military 12 Correctional Facility 13 Church 14 International Travel 15 Other