CASE REPORT FORM
Measles, Mumps, Rubella
Measles Mumps Rubella
EpiSurv No.
Disease Name
Measles
Mumps
Rubella
Reporting Authority
Name of Public Health Officer responsible for case
Notifier Identification
Reporting source*
General Practitioner
Hospital-based Practitioner
Laboratory
Self-notification
Outbreak Investigation
Other
Name of reporting source
Organisation
Date reported*
Contact phone
Usual GP
GP phone
Practice
GP/Practice address
Number
Street
Suburb
Town/City
Post Code
GeoCode
Case Identification
Name of case*
Surname
Given Name(s)
NHI number*
Current address*
Email
Number
Street
Suburb
Town/City
Post Code
Phone (home)
Phone (work)
GeoCode
Phone (other)
Case Demography
Location
TA*
DHB*
Date of birth*
Sex*
OR
Male
Female
Age
Days
Indeterminate
Months
Years
Unknown
Occupation*
Occupation location
Place of Work
School
Pre-school
Name
Address
Number
Street
Suburb
Town/City
Alternative location
Post Code
Place of Work
School
GeoCode
Pre-school
Name
Address
Number
Street
Suburb
Town/City
Post Code
GeoCode
Ethnic group case belongs to* (tick all that apply)
NZ European
Maori
Samoan
Cook Island Maori
Niuean
Chinese
Indian
Tongan
Other (such as Dutch, Japanese, Tokelauan)
*(specify)
Page 1 of 4
Measles Mumps Rubella
EpiSurv No.
Basis of Diagnosis
CLINICAL CRITERIA
Fits Clinical Description*
Measles
Yes
No
Unknown
Fever 38.0 C present at time of rash onset
Yes
No
Unknown
Maculopapular rash
Yes
No
Unknown
Cough
Yes
No
Unknown
Coryza
Yes
No
Unknown
Conjunctivitis
Yes
No
Unknown
Koplik's spots
Yes
No
Unknown
Fever
Yes
No
Unknown
Acute swelling of parotid or other salivary gland
for more than 2 days
Yes
No
Unknown
Orchitis
Yes
No
Unknown
Fever
Yes
No
Unknown
Maculopapular rash
Yes
No
Unknown
Arthritis/arthralgia
Yes
No
Unknown
Lymphadenopathy
Yes
No
Unknown
Conjunctivitis
Yes
No
Unknown
If yes, date of onset of rash*
Mumps
Rubella
If yes, date of onset of rash*
LABORATORY CRITERIA
Laboratory confirmation of disease*
Yes
No
Not Done
Awaiting Results
Confirmation method
Isolation of virus from clinical specimen
Positive IgM antibody
Significant rise in IgG antibody level
Nucleic acid testing (NAT)
Genetic characterisation (specify)
EPIDEMIOLOGICAL CRITERIA
Contact with a confirmed case*
Yes
No
Unknown
If yes, specify the EpiSurv number of the confirmed case*
CLASSIFICATION*
Under investigation
Probable
Confirmed
Not a case
Clinical Course and Outcome
Date of onset*
Hospitalised*
Yes
Date hospitalised*
Approximate
Unknown
No
Unknown
Unknown
Hospital*
Died*
Yes
No
Date died*
Was this disease the primary cause of death?*
Unknown
Unknown
Yes
No
Unknown
If no, specify the primary cause of death*
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Measles Mumps Rubella
EpiSurv No.
Outbreak Details
Is this case part of an outbreak (i.e. known to be linked to one or more other cases of the same disease)?*
If yes, specify Outbreak No.*
Yes
Risk Factors
Contact with another case of the disease during the incubation period for
this disease*
Yes
No
Unknown
Attendance at school, pre-school or childcare during the incubation period
for this disease*
Yes
No
Unknown
Was the case overseas during the incubation period for this disease?*
Yes
No
Unknown
If yes, date arrived in New Zealand*
Specify countries visited* (from most recent to least recent)
Country/Region*
Date Entered*
Date Departed*
Last*
Second Last*
Third Last*
Other risk factors for measles, mumps or rubella (specify)*
Source (measles and rubella only)
What was the source of the virus?*
Imported
If imported, specify country*
Import-related
Endemic
Unknown
Specify region /city*
If import-related, specify the EpiSurv number of the source case*
If the case was infected in New Zealand, specify the DHB where contact occurred*
Protective Factors
At any time prior to onset, had the case been immunised with the MMR or
appropriate monovalent vaccine?*
If yes specify, vaccine details*
First administered dose:*
Date given*
MMR/Monovalent
Weeks
Patient/caregiver recall
Second administered dose:*
Unknown
MMR/Monovalent
Months
Years
Months
Years
Documented
Not given
Or age when second dose was given
Source of information*
No
Unknown
Or age when first dose was given
Source of information*
Date given*
Yes
Unknown
Weeks
Patient/caregiver recall
Documented
Management
CASE MANAGEMENT
Date case investigation was started*
(measles and rubella only)
Date case investigation was completed*
(measles and rubella only)
Case excluded from work or school/pre-school/childcare for
appropriate period*
Yes
No
NA
Was case pregnant (rubella only)?*
Yes
No
Unknown
If yes, gestation period*
Unknown
(weeks) at time of onset
Page 3 of 4
Measles Mumps Rubella
EpiSurv No.
Management
CONTACT MANAGEMENT
Did the case have any contacts (measles and rubella only)?*
Yes
No
Unknown
If yes, specify number and management*
Number
identified
Category
Number
susceptible
Number given
MMR
(measles only)
Number
Number given
declined MMR
IG
(measles only) (measles only)
<15 months of age
15 months and over (not pregnant)
Pregnant
Flight details if case infectious while on board an international flight (measles only)*
Last flight
2nd to last flight
3rd to last flight
4th to last flight
Flight number(s)
Date of departure
Unimmunised susceptibles excluded from school/pre-school/
childcare for appropriate period*
Yes
No
NA
Unknown
Comments*
Version 3 June 2015
* core surveillance data, ~ optional data
Page 4 of 4
