Fillable KANSAS PERTUSSIS (WHOOPING COUGH) REPORTING FORM (Kansas Department of Health and Environment)

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KANSAS PERTUSSIS (WHOOPING COUGH) REPORTING FORM (Kansas Department of Health and Environment)

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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
(Page 1 of 2)
(Revised 05/2018)
Today’s date:
PATIENT INFORMATION
Name:
Last First Middle
Mobile phone: Home phone:
Residential address:
City: State: Zip:
Date of Birth (if unknown, provide age):
Race: Ethnicity: Sex:
Associated with high-risk setting or institution?
Name and city of high-risk setting or institution: Grade/Room:
D
ISEASE OR CONDITION INFORMATION
Has the patient/guardian been notified of pertussis diagnosis:
Hospitalized? Died?
Laboratory name: Specimen collection date:
Test(s) performed: Test result(s):
FACILITY AND PHYSICIAN INFORMATION
Facility name: Facility city:
Physician name: Phone #:
Name of person reporting: Phone #:
T
REATMENT INFORMATION
Treated?
P
LEASE CONTINUE TO PAGE TWO FOR SUPPLEMENTAL INFORMATION FOR REPORTING PERTUSSIS
White
Black
Asian
American Indian / Alaska Native
Native Hawaiian / Pacific Islander
Hispanic
Non-Hispanic
Male
Female
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Pregnant?
Daycare Health Care Food Handler School
Nursing Home Correctional Shelter Other
Yes
No
Unknown
Treatment type, dosage, and duration:
Yes No
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
(Page 2 of 2)
S
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):
Inspiratory whoop:
Post-tussive emesis:
Infants younger than one year old, apnea:
Infants younger than one year old, cyanosis:
S
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 No Unknown
Yes No Unknown
Yes No Unknown
Yes No Unknown
Yes No Unknown
Yes (enter below) No Unknown
Medical contraindication Religious exemption Parental objection Alternative immunization schedule
Philosophical objection
Under age for vaccination (younger than 2 months)
Unknown/other
Yes No Unknown
Yes No Unknown
(Revised 08/2018)
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KANSAS PERTUSSIS (WHOOPING COUGH) REPORTING FORM (Kansas Department of Health and Environment)

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Completed 14 August 2020

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