Condition
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Today M-D-Y MM/DD/YYYY
Measles symptoms appear 7 to 14 days after contact with the virus.
Common early symptoms include: High fever, up to 105°F Cough Runny nose Red or watery eyes Koplik spots (tiny white spots inside the mouth) may appear 2-3 days after symptoms begin.
Measles rash appears 3 to 5 days after the first symptoms.
A rash of flat red spots appear on the face and spread to the neck, chest, arms, legs and feet Small raised bumps may appear on top of the flat red spots The spots may become joined together as they spread from the head to the rest of the body
Healthcare Provider Measles Control Measures
Mask the presumptive measles patient immediately with procedure or surgical mask. Isolate patient in a negative pressure room, if available, or in a private room with the door closed. Do not use any regular exam room for at least 2 hours after the patient has left. Do not allow measles patients to remain in the waiting room or other common areas. Only staff with presumptive evidence of immunity should enter the patient's room. Staff should use respiratory protection that is at least as protective as a fit-tested, NIOSH-certified, disposable filtering facepiece respirator regardless of presumptive evidence of immunity. https://www.cdc.gov/infectioncontrol/guidelines/measles/index.html
Reporter's Facility: Reporter's Phone: Facility Address:
Reporter's First Name:
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Reporter's Last Name:
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Reporter's Facility Name:
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Reporter's Street Address:
Reporter's City
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Reporter's State:
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Reporter's Zip Code:
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Reporter's Call Back Number:
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Provider's Name: Call Back Phone Number: Email:
Provider's Name
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Provider Call Back Number
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###-###-####
Provider's Email Address
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Patient's Name Date of Birth Patient's Address
Patient's First Name:
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Patients's Last Name:
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Patient's Date of Birth:
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M-D-Y MM-DD-YYYY
Patient's Age (in years):
View equation If patient < 18 years old , provide parent/proxy's name:
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Patient's Street Address of Residence:
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123 Main St
Patient's City of Residence:
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Patient's State of Residence:
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Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Johnston Atoll Marshall Islands Northern Mariana Islands Palau Midway Islands Puerto Rico U.S. Minor Outlying Islands Navassa Island Virgin Islands of the U.S. Wake Island Baker Island Howland Island Jarvis Island Kingman Reef Palmyra Atoll
Patient's County of Residence:
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Autauga County Baldwin County Barbour County Bibb County Blount County Bullock County Butler County Calhoun County Chambers County Cherokee County Chilton County Choctaw County Clarke County Clay County Cleburne County Coffee County Colbert County Conecuh County Coosa County Covington County Crenshaw County Cullman County Dale County Dallas County De Kalb County Elmore County Escambia County Etowah County Fayette County Franklin County Geneva County Greene County Hale County Henry County Houston County Jackson County Jefferson County Lamar County Lauderdale County Lawrence County Lee County Limestone County Lowndes County Macon County Madison County Marengo County Marion County Marshall County Mobile County Monroe County Montgomery County Morgan County Perry County Pickens County Pike County Randolph County Russell County Saint Clair County Shelby County Sumter County Talladega County Tallapoosa County Tuscaloosa County Walker County Washington County Wilcox County Winston County
Complete if Alabama resident.
Patient's Zip Code of Residence:
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##### or #####-####
Patient's Phone Number:
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###-###-####
Symptom Onset Date Fever: Cough: Coryza: Conjunctivitis: Koplik Spots: Rash:
Fever
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Yes No Unknown
Fever Onset Date:
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Today M-D-Y
Measured Temp
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Fahrenheit Celsius
Cough:
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Yes No Unknown
Cough Onset Date:
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Today M-D-Y
Coryza
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Yes No Unknown
Coryza Onset Date:
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Today M-D-Y
Conjunctivitis:
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Yes No Unknown
Conjunctivitis Onset Date:
Today M-D-Y
Koplik spots:
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Yes No Unknown
Koplik Spots Onset Date:
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Today M-D-Y
Rash:
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Yes No Unknown
Rash Onset Date:
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Today M-D-Y
Did the rash start on the face?
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Yes
No
Describe where the rash began and how it spread:
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Has the patient been administered antibiotics recently? Patients with throat or ear infections occasionally develop a rash following administration of antibiotics.
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Yes No Unknown
Does the patient have any other current diagnoses or prescriptions that could cause a rash?
Yes No
Please describe other diagnosis or prescription being considered as a cause for the rash:
Have other rash–causing illnesses such as parvovirus B19, enteroviruses, or human herpesvirus–6 (roseola) been considered?
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Yes, considered and have ruled out
Yes, considered and have not ruled out
No, have not considered
Has any other testing been performed?
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Yes No Unknown
Other tests performed
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Has this patient received a measles-containing vaccine?
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Yes No Unknown
Data sources used for immunization history
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REMINDER: verbal attestation does not qualify
Total Number of Doses Received:
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Dose 1 Date:
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Today M-D-Y
Dose 2 Date:
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Today M-D-Y
Dose 3 Date:
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Today M-D-Y
Is there laboratory evidence of immunity or measles confirmation?
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In the past 21 days, has the patient traveled:
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Check all that apply
Provide 'Outside the county, but within Alabama' details of locations and dates.
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Provide 'Outside Alabama, but within US' details of locations and dates.
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Provide 'Outside the continental US' details of locations and dates.
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In the past 21 days, has the patient been in contact with a known measles case?
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Yes No Unknown
In the past 21 days, has the patient had contact with an international visitor?
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Yes No Unknown
You may upload up to three laboratory reports and/or supporting documents for this patient. Patient information must be included in any upload.
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0 1 2 3
Approved or Denied for Testing
Approved
Denied
ADPH approval or denial determination made by:
First and last name
Select the Specimen Then Enter Information
Select Swab and/or Serum
Swab Specimen
BCL Lab ID Date Received at BCL
Date Sent from BCL
Shipped to Result
Serum Specimen
BCL Lab ID Date Received at BCL
Date Sent from BCL
Shipped to Result
SWAB: Date Received at BCL
Today M-D-Y
SERUM: Date Received at BCL
Today M-D-Y
Today M-D-Y
SERUM: Date Sent From BCL
Today M-D-Y
Reporter Type or On Behalf Of:
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Other
HIDDEN FIELD
Patient's Race:
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White Black or African American Asian American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander Other Unknown
If patient's race is other , please specify:
Patient's Ethnicity:
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Hispanic or Latino Not Hispanic or Latino Unknown
Patient's Gender:
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Female Male Unknown
REPORT Card Complete?
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Complete
Please educate staff and patients with the Measles Fast Facts flyer: http://www.alabamapublichealth.gov/immunization/assets/measles_flyer.pdf
Measles symtpoms:
Common early symptoms include: High fever, up to 105 °F Cough Runny nose Red or watery eyes Two to three days after symptoms begin, the patient may have: Tiny white spots appear inside the mouth Three to five days after the symptoms begin, the patient may have: A rash of flat red spots appear on the face and spread to the neck, chest, arms, legs and feet Small raised bumps appear on the flat red spots * must provide value
Yes No
This is the previous field - removed Y/N question but Hiding question to keep historical data
Are you requesting measles PCR testing or a consultation with a physician?
Measles PCR testing only
Physician consultation only
BOTH Measles PCR testing and Physician consultation
Please educate staff and patients with the Measles Fast Facts flyer: http://www.alabamapublichealth.gov/immunization/assets/measles_flyer.pdf
Measles symtpoms:
Common early symptoms include: High fever, up to 105 °F Cough Runny nose Red or watery eyes Two to three days after symptoms begin, the patient may have: Tiny white spots appear inside the mouth Three to five days after the symptoms begin, the patient may have: A rash of flat red spots appear on the face and spread to the neck, chest, arms, legs and feet Small raised bumps appear on the flat red spots Please select symptoms.
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Temperature Onset Date:
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Today M-D-Y
Cough Onset Date:
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Today M-D-Y
Coryza Onset Date:
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Today M-D-Y
Conjunctivitis Onset Date:
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Today M-D-Y
Koplik Spots Onset Date:
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Today M-D-Y
Rash Onset Date:
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Today M-D-Y
If the rash did not appear on the face first, describe where the rash began and how it has spread:
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Was patient found in ImmPRINT?
Yes
No
I am not able to login to ImmPRINT
Date of First Valid MMR Dose
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Today M-D-Y
Date of Second Valid MMR Dose (if given):
Today M-D-Y
Did the patient have one or more valid doses of MMR in ImmPRINT's Tree Vaccine History or Forecaster?
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Yes
No
Is there alternative documentation of adequate measles vaccination?
Yes No
Please review the CDC Evidence of Immunity Criteria :
"Acceptable presumptive evidence of immunity against measles includes at least one of the following:
written documentation of adequate vaccination: one or more doses of a measles-containing vaccine administered on or after the first birthday for preschool-age children and adults not at high risk two doses of measles-containing vaccine for school-age children and adults at high risk, including college students, healthcare personnel, and international travelers laboratory evidence of immunity* laboratory confirmation of measles birth before 1957 Healthcare providers should not accept verbal reports of vaccination without written documentation as presumptive evidence of immunity. For additional details about evidence of immunity criteria, see Table 3 in Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices (ACIP).
*People who have negative or equivocal results for measles IgG should be vaccinated or revaccinated. In some cases it is not possible to vaccinate a patient, and you may need to test them with a second line diagnostic assay to determine whether they are immune to measles. Because the sensitivity and specificity of commercial measles IgG assays vary, state public health departments can provide information on appropriate second line assays.
https://www.cdc.gov/measles/hcp/index.html#immunity
Please review the CDC Measles Serology website for important information on testing: "In countries such as the United States where endemic circulation of measles has been eliminated, most suspected cases are not measles, and rash and fever illnesses are more likely due to a number of other rash-causing illnesses such as parvovirus B19, enteroviruses, or human herpesvirus-6 (roseola). The presence of rheumatoid factor (RF) can also result in a false positive IgM. Indirect EIA's appear to be more affected by RF than IgM capture assays. Additionally, patients with throat or ear infections occasionally develop a rash following administration of antibiotics. Subsequent serologic specimens sent for measles IgM testing may result in a false positive test. " https://www.cdc.gov/measles/lab-tools/serology.html
Has any other testing been performed and ruled out?
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Yes
No
*** If approved for testing, a swab AND serum for serology must be collected. *** Has the patient traveled outside the county, state or country within the last 3 weeks?
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Yes
No
Submit
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