Family History of Cough: Indicate whether anyone in the decedent’s family or immediate household experienced acute cough illness within the 21 days prior to the decedent’s own cough onset. Select any of the underlying health issues Underlying Health Issues General Instructions: – listed on the worksheet that the decedent experienced prior to or during the course of illness preceding their death. Refer to Appendix 2 for a complete description of each option. Co-Infections and Other Diagnoses General Instructions: Select any of the diseases listed on – the worksheet diagnosed via laboratory testing that were identified during the decedent’s course of illness preceding their death. Decedent Pertussis Vaccination History General Instructions: Provide all documented doses – of pertussis-containing vaccines administered to the decedent at least two weeks prior to their cough onset. Include each of the pieces of information listed below. vaccine type, date of vaccine administration, and vaccine manufacturer and/or lot number, where available. Refer to Appendix 3 for a complete list of vaccine types, names and manufacturers. Vaccine (Type or Name): For each documented dose of vaccine, record the type and/or brand name. For each dose of vaccine, please list the date of Date Administered: documented administration in MM/DD/YYYY format. If only month and year are available, fill in for ‘15’ the day portion of the date. Manufacturer and/or Lot Number: Record the manufacturer and or lot number associated with the dose of vaccine.
Family History of Cough: Indicate whether anyone in the decedent’s family or immediate household experienced acute cough illness within the 21 days prior to the decedent’s own cough onset. Underlying Health Issues – General Instructions: Select any of the underlying health issues listed on the worksheet that the decedent experienced prior to or during the course of illness preceding their death. Refer to Appendix 2 for a complete description of each option. Co-Infections and Other Diagnoses – General Instructions: Select any of the diseases listed on the worksheet diagnosed via laboratory testing that were identified during the decedent’s course of illness preceding their death. Decedent Pertussis Vaccination History – General Instructions: Provide all documented doses of pertussis-containing vaccines administered to the decedent at least two weeks prior to their cough onset. Include each of the pieces of information listed below. vaccine type, date of vaccine administration, and vaccine manufacturer and/or lot number, where available. Refer to Appendix 3 for a complete list of vaccine types, names and manufacturers. Vaccine (Type or Name): For each documented dose of vaccine, record the type and/or brand name. Date Administered: For each documented dose of vaccine, please list the date of administration in MM/DD/YYYY format. If only month and year are available, fill in ‘15’ for the day portion of the date. Manufacturer and/or Lot Number: Record the manufacturer and or lot number associated with the dose of vaccine.
appendix12-1-pertussis-instruc.docx