KANSAS PERTUSSIS (WHOOPING COUGH) REPORTING FORM
Fax this form to your local health department or KDHE: 877-427-7318
Please include pertussis laboratory results, if available
This form is available at: www.kdheks.gov/epi/disease_reporting.html
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UPPLEMENTAL PERTUSSIS INFORMATION – CLINICAL SYMPTOMS
Cough onset date: Current cough duration: days
Does patient present or report any of the following symptoms?
Paroxysmal cough (bursts of numerous, rapid coughs):
Infants younger than one year old, apnea:
Infants younger than one year old, cyanosis:
UPPLEMENTAL PERTUSSIS INFORMATION – VACCINATION STATUS
Has patient previously received any pertussis-containing vaccine?
Vaccine One date received: Type (e.g. DTaP, Tdap):
Vaccine Two date received: Type (e.g. DTaP, Tdap):
Vaccine Three date received: Type (e.g. DTaP, Tdap):
Vaccine Four date received: Type (e.g. DTaP, Tdap):
Vaccine Five date received: Type (e.g. DTaP, Tdap):
Vaccine Six date received: Type (e.g. DTaP, Tdap):
If unimmunized (or under-immunized), please select reason(s) below:
Does the patient have contact with any high-risk* persons?
*High-risk persons are defined as:
• Infants younger than one;
• Pregnant women in third trimester;
• Persons with pre-existing health conditions that may be exacerbated by a pertussis infection;
• Persons exposed to patient that have regular contact with any high-risk persons above;
Please note, your local health department can assist in identifying high-risk contacts
Was chemoprophlaxis given/recommended to ALL household contacts and high-risk contacts?
If yes, please list names/relationships:
Yes (enter below) No Unknown
Medical contraindication Religious exemption Parental objection Alternative immunization schedule
Under age for vaccination (younger than 2 months)