Measles Case Form

Sample Measles Outbreak Case Investigation and Follow-up Form
Form Completed by____________________ Final Status:  Confirmed  Probable  Ruled out

Date Form Completed __________________ Index Case:  Yes No Unknown
Public Health Unit_____________________ Secondary Case:  Yes No Unknown
Case ID Number: _______________________
Case Identification
Last Name: _____________________________ First Name: _______________________________
Date of Birth: YYYY/MM/DD________________ Sex:  Male  Female Other 
Age at Onset: ___________________________
Address: _______________________________ Province: ________
City/Town: ____________________________ Family Physician: _________________________
Postal Code: ___________ Phone Number: __(____)________________
Phone Number: __ (____) ________________ E-mail:_______________________________
 Home  Work  Cell  Other
Parent/Guardian/Next of Kin: __________________________
Clinical Information
Symptoms:
Maculopapular rash Coryza
Date of onset:_____/_______/_______ Duration:________days Conjunctivitis
Where did rash start? □Face □Trunk □ Extremities Cough
Is rash generalized? □ Yes □ No □ Unknown Pharyngitis
Fever: Koplik’s spots
Date of onset:_____/_______/_______ Max Temp:________ºC Light Sensitivity
 Oral  Rectal  Axillary Other
Hospitalization:  Yes  No Unknown

If yes, Name of Hospital: _________________
Date admitted: _________________ Date discharged: ________________
Attended Out-patient Clinic?  Yes  No Unknown

If yes, Name of Clinic: ____________________ Date of visit: ______________________
Clinical Outcome:
 Recovered  without residual effects with residual effects
 Residual effects:
Period of Communicability
 Otitis Media Pneumoniae Encephalitis Meningitis  Bronchitis  Diarrhea  Other____________
Fatal
Date of Death________________
Death Due to Measles/Complications: Yes No
Unknown
Calculation of Incubation and Communicability Period

History of Immunization
History of measles disease:  Yes  No Unknown
Received measles-containing vaccine in the past:  Yes No Unknown
If no immunization, specify reason: ______________________________________________________
Vaccine Name Date Received Age Province/Territory/ Lot Number

(YYYY/MM/DD) (Yrs) Or Country (if known)
1.
2.
3.
Laboratory Data
Laboratory Information
Sample 1 Sample 2 Sample 3 Sample 4

Type of Sample  Nasopharyngeal  Nasopharyngeal  Nasopharyngeal  Nasopharyngeal
aspirate/swab aspirate/swab aspirate/swab aspirate/swab
 Throat swab  Throat swab  Throat swab  Throat swab
 Serum  Serum  Serum  Serum
 Urine  Urine  Urine  Urine
 Other:_________  Other:_________  Other:__________  Other:__________
Identification #
Date taken Day/Month/Year Day/Month/Year Day/Month/Year Day/Month/Year
Date Sent
FOR LABORATORY USE
Date Received Day/Month/Year Day/Month/Year Day/Month/Year Day/Month/Year
Id # in
laboratory
Type of test  IgM EIA capture  IgM EIA capture  IgM EIA capture  IgM EIA capture
 IgM EIA indirect  IgM EIA indirect  IgM EIA indirect  IgM EIA indirect
 IgG EIA  IgG EIA  IgG EIA  IgG EIA
 Viral isolation  Viral isolation  Viral isolation  Viral isolation
 PCR  PCR  PCR  PCR
 Other test  Other test  Other test  Other test
Results  Positive  Positive  Positive  Positive
 Negative Negative  Negative  Negative
 Indeterminate Indeterminate  Indeterminate  Indeterminate
 Inadequate sample Inadequate sample  Inadequate  Inadequate sample
 Not processed  Not processed sample  Not processed
 Not processed
Results dates Day/Month/Year Day/Month/Year Day/Month/Year Day/Month/Year
comment
Exposure Information:
Have you had contact with anyone who was told they have measles:  Yes  No
If yes, Name of Person: ___________________________________________________
Social activities in the 7 days before case developed symptoms

Date(s)
Social Activities in the past 7 days Activity Details
(YYYY/MM/DD)
 Used public transit
 Visited or volunteered at a hospital
 Attended church/religious function
 Attended family gathering
 Attended meeting or conference
 Attended concert, theatre or sporting event
 Participated in shopping event
 Participated in recreational activity
 Dined at coffee shop/cafeteria/food court
 Dined at restaurant
 Patronised bar or night club
 Other activities
Date(s)
Travel History in the past 7 days: Location
(YYYY/MM/DD)
 Domestic
 International
Occupational Information
Occupation: Name of Employer:
Day Care/School/Educational Institution

Do you attend a day care, school or post-secondary institution?  Yes  No
If YES, Name of School/Institution: Grade/Level/Year:
Timetable (Please attach if available):
Living Arrangements
What type of residence do you live in?
 House  Apartment  University residence  Hotel/Motel  Group Home or Long-Term Care Facility  Other
(please specify)______________________________________________
Do you live, room or share accommodation with anyone?  Yes  No
If YES, with how many people?
Do you receive home care?  Yes  No
Close Contact Information

Please list all close contacts, including your spouse, partner, siblings, children, family members, roommates and other
people you live with
Immunization
Status
Not Immunized
Contact Date of Birth (0)
Contact Name Phone (YYYY/MM/DD) Immunized - 1
Relationship or Dose (1) Occupation
(Surname, Given Name) Number
Age Immunized - 2
Dose (2)
History of
Measles (8)
Comments/Notes:
Classification
Measles-laboratory confirmed 
Measles probable case 
Discarded 
Basis for classification:  Laboratory results  Epidemiological link  Clinical Presentation
Investigator: ___________________ Institution: _______________________ Date:________________________

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Sample Measles Outbreak Case Investigation and Follow-up Form

Form Completed by____________________ Final Status:  Confirmed  Probable  Ruled out

 Oral  Rectal  Axillary Other

Hospitalization:  Yes  No Unknown

Attended Out-patient Clinic?  Yes  No Unknown

Calculation of Incubation and Communicability Period

Vaccine Name Date Received Age Province/Territory/ Lot Number

Sample 1 Sample 2 Sample 3 Sample 4

Social activities in the 7 days before case developed symptoms

Day Care/School/Educational Institution

Close Contact Information

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