Varicella Surveilliance Worksheet
9
Acute
Convalescent
Vaccine History
Vaccinated
Received varicella-containing vaccine?
Yes
Y
No
N
Unknown
U
Reason
What was the reason for not being vaccinated?
Religious exemption
1
Medical contradiction
2
Philosophical objection
3
Lab. evidence of previous disease
4
MD Diagnosis of previous disease
5
Under age for vaccination
6
Parental refusal
7
Other
8
Unknown
9
Number of doses recieved ON or AFTER 1st birthday
Vaccinations
MMR
A
Varicella
B
Other
O
Unknown
U
Merck
M
Other
O
Unknown
U
Record another vaccination