Form 0920-0978 2 months to

Patient’s Name

Patient’s Date of Birth

/

/

– Patient identifier information is not transmitted to CDC –

ACTIVE BACTERIAL CORE SURVEILLANCE (ABCs) INVASIVE
PNEUMOCOCCAL DISEASE IN CHILDREN (aged ≥2 months to <5 years)
StateID:

Date of positive culture

/

/

Child has never received vaccines

VACCINES

Dose #

Dates of immunizations

Date form completed

/

OMB No. 0920-0978

/

Vaccination history unknown

Manufacturer

Vaccine name

Lot #

1

Pneumococcal
conjugate vaccine
Prevnar13® (PCV13)

Dose #1 source:

Medical Chart

Registry

Primary Care Provider

Other

2

Dose #2 source:

Medical Chart

Registry

Primary Care Provider

Other

Medical Chart

Registry

Primary Care Provider

Other

Medical Chart

Registry

Primary Care Provider

Other

Medical Chart

Registry

Primary Care Provider

Other

Medical Chart

Registry

Primary Care Provider

Other

Medical Chart

Registry

Primary Care Provider

Other

Medical Chart

Registry

Primary Care Provider

Other

3

Dose #3 source:
4

Dose #4 source:
5

Dose #5 source:
6

Dose #6 source:

Pneumococcal
polysaccharide vaccine
Pnuemovax®23 (PPSV23)

1

Dose #1 source:
2

Dose #2 source:

Diphtheria/Tetanus/
Pertussis (DTP or DTaP)

1

**For combination vaccines (e.g. Trihibit, Tetramune, ActHIB/DTwP) enter information for each
vaccine component**

2

Health Care Provider Information

3

Was health care provider information available from the
following sources?

4

Medical Chart:

5

Haemophilus influenzae
type B (Hib)

1
2

Did Not Check

Vaccine Registry:

Did Not Check

Parent/Guardian:

Did Not Check

Refused

If yes to any sources,
How many providers were contacted? ___

3
4

Person completing the form (please print):
Name
Please return form to:

Title

Phone: (

)

Phone: (

)

Fax:
Fax:

(
(

)
)

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless
it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden to CDC,
CDC/ATSDR Reports Clearance Oflcer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA(0920-0978). Do not send the completed form to this address.
CDC 52.15A REV. 8-2018