Free 51849.pdf - Indiana

Varicella (Chickenpox) Disease Surveillance Monthly Report
State Form 41849 (7-04)

Indiana State Department of Health ­ Epidemiology Resource Center
Report all cases of chickenpox, including those reported by parent via telephone (please ask parent or patient about grade of lesions). If there were no reported cases, please check this box
Name of Provider/School/Day-care Center: Street Address: State: City: ZIP Code: Telephone #: (Include Area Code)

Month and Year of Report:

IN

Name of Child

Date of Birth

Date of Rash Onset

Received Varicella Vaccine
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No

Vaccination Date(s)
I I I I I I I I I I

Severity of Disease*
II II II II II II II II II II III III III III III III III III III III

Name of Person Submitting Report:

Date of Report:

*Severity of Disease: Estimate the number of chickenpox lesions/spots easily counted by parent or nurse. I - 50 spots or less, easily counted within 30 seconds. II - 50-500 spots (between Grade I and Grade III). III - 500 or more spots or spots clumped so closely together that little normal skin is visible.

Please submit this report (by fax, mail, or e-mail) each month to:

Epidemiologist, Epidemiology Resource Center, Indiana State Department of Health, 2 North Meridian Street, Indianapolis, Indiana 46204; Fax: 317.234.2812; Voice: 317.233.7112; E-mail: [email protected]