Condition* must provide value
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
Date of Report: Today M-D-Y MM/DD/YYYY
Reporter's First Name:* must provide value
Reporter's Last Name:* must provide value
Reporter's Facility Name:* must provide value
Reporter's Phone Number:
Provider's Name* must provide value
Provider Call Back Number* must provide value
###-###-####
Provider's Email Address* must provide value
Patient's First Name:* must provide value
Patients's Last Name:* must provide value
Patient's Date of Birth:* must provide value
Today M-D-Y MM-DD-YYYY
Please note that patient birth prior to 1957 is a CDC Evidence of Immunity Criterion : https://www.cdc.gov/measles/hcp/index.html#immunity
If there is reason to continue to suspect measles please continue completing this form.
If patient < 18 years old , provide parent/proxy's name:* must provide value
Patient's Street Address of Residence:* must provide value
123 Main St
Patient's City of Residence:* must provide value
Patient's State of Residence:* must provide value
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:* must provide value
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: ##### or #####-####
Patient's Phone Number:* must provide value
###-###-####
Please check ImmPRINT to verify whether or not the patient has received the recommended measles vaccines.
Click HERE to login to ImmPRINT.
https://siis.state.al.us/ImmPrint/login/login.aspx
One or more valid doses of documented MMR vaccine is evidence of immunity.
Was patient found in ImmPRINT? Yes
No
I am not able to login to ImmPRINT
Did the patient have one or more valid doses of MMR in ImmPRINT's Tree Vaccine History or Forecaster?
* must provide value
Yes
No
Is there alternative documentation of adequate measles vaccination?
Yes
No
Date of First Valid MMR Dose* must provide value
Today M-D-Y
Date of Second Valid MMR Dose (if given): Today M-D-Y
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.* must provide value
Temperature ≥101°F or 38.3°C
Cough
Coryza
Conjunctivitis
Koplick Spots
Generalized, maculopapular rash
Temperature Onset Date:* must provide value
Today M-D-Y
Measured Temp* must provide value
Cough Onset Date:* must provide value
Today M-D-Y
Coryza Onset Date:* must provide value
Today M-D-Y
Conjunctivitis Onset Date:* must provide value
Today M-D-Y
Koplick Spots Onset Date:* must provide value
Today M-D-Y
Rash Onset Date:* must provide value
Today M-D-Y
Did the rash start on the face?* must provide value
Yes
No
If the rash did not appear on the face first, describe where the rash began and how it has spread:* must provide value
Has the patient traveled outside the county, state or country within the last 3 weeks?* must provide value
Yes
No
If yes, please select all that apply.* must provide value
Outside the county, but within Alabama
Outside Alabama, but within US
Outside the continental US
Provide 'Outside the county, but within Alabama' details of locations and dates.* must provide value
Provide 'Outside Alabama, but within US' details of locations and dates.* must provide value
Provide 'Outside the continental US' details of locations and dates.* must provide value
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
Is there laboratory evidence of immunity or measles confirmation?
Yes, Laboratory evidence of immunity
Yes, Laboratory confirmation of measles
No
Has the patient been administered antibiotics recently? Patients with throat or ear infections occasionally develop a rash following administration of antibiotics.
* must provide value
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?* must provide value
Yes, considered and have ruled out
Yes, considered and have not ruled out
No, have not considered
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
Yes
No
Other tests performed* must provide value
You may upload up to three laboratory reports and/or supporting documents for this patient. Patient information must be included in any upload.* must provide value
0 1 2 3
Document/Result 1
Document/Result 2
Document/Result 3
Please review the ADPH Guidance for Measles Specimen Collection, Shipping and Testing:
http://alabamapublichealth.gov/immunization/guidanceformeaslesspecimencollectionshippingtesting.pdf
Do not ship specimens before notification of approval for measles PCR testing.
*** If approved for testing, a swab AND serum for serology must be collected. *** Approved or Denied for Testing Approved
Denied
ADPH approval or denial determination made by: First and last name
Select the Specimen Then Enter Information SWAB: BCL Lab ID
SERUM: BCL Lab ID
SWAB: Date Received at BCL Today M-D-Y
SERUM: Date Received at BCL Today M-D-Y
SWAB: Date Sent From BCL Today M-D-Y
SERUM: Date Sent From BCL Today M-D-Y
SWAB: Shipped to
Wisconsin
CDC
SERUM: Shipped to
Wisconsin
CDC
SWAB: Result
Positive
Negative
Indeterminant
Unsat
SERUM: Result
Positive
Negative
Indeterminant
Unsat
Reporter Type or On Behalf Of:* must provide value
Other
Investigator Type Code: HIDDEN FIELD
Patient's Race:* must provide value
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:* must provide value
Hispanic or Latino Not Hispanic or Latino Unknown
Patient's Gender:* must provide value
Female Male Unknown
REPORT Card Complete?* must provide value
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
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