ࡱ> q  Lbjbjt+t+ )6AA*H]FFFFFFFZZZZ8tZu-`fffff> D"$+++++++$+.00,qF $ff $ $,l&FFffl&l&l& $>FfFf+ZZFFFF $+l&rl&+FF+ftl_ZZJ&"+New Jersey Department of Health Vaccine Preventable Diseases Program PO Box 369 Trenton, NJ 08625-0369 MUMPS SURVEILLANCE WORKSHEETCase Status  FORMCHECKBOX Confirmed  FORMCHECKBOX Probable  FORMCHECKBOX Not a CasePatient Name (Last, First)  FORMTEXT      Telephone No.  FORMTEXT      CDRSS #  FORMTEXT      E#  FORMTEXT      Street Address  FORMTEXT      City  FORMTEXT      Zip  FORMTEXT      County  FORMTEXT      Reporting Source  FORMTEXT      Treating Physician  FORMTEXT      Address of Physician  FORMTEXT      Telephone No.  FORMTEXT      Dates Physician Saw  FORMTEXT      Name of Investigator  FORMTEXT      Name of Agency  FORMTEXT      Telephone No.  FORMTEXT      Hospital  FORMTEXT      Hospital Record Number  FORMTEXT      Hospital Address  FORMTEXT      Telephone No.  FORMTEXT      Birth Date  FORMTEXT __ __ / __ __ / __ __ (mm/dd/yy)Age  FORMTEXT __ __ __ (Unknown = 999)Age Type 0  FORMCHECKBOX  0-120 Years 2  FORMCHECKBOX  0-2 Weeks 9  FORMCHECKBOX  Age Unknown 1  FORMCHECKBOX  0-11 Months 3  FORMCHECKBOX  0-28 DaysEthnicity H  FORMCHECKBOX  Hispanic N  FORMCHECKBOX  Not Hispanic U  FORMCHECKBOX  UnknownRace N  FORMCHECKBOX  Native American/Alaskan Native W  FORMCHECKBOX  White A  FORMCHECKBOX  Asian/Pacific Islander O  FORMCHECKBOX  Other B  FORMCHECKBOX  African American U  FORMCHECKBOX  UnknownSex M  FORMCHECKBOX  Male F  FORMCHECKBOX  Female U  FORMCHECKBOX  UnknownEvent Date  FORMTEXT __ __ / __ __ / __ __ (mm/dd/yy)Event Type 1  FORMCHECKBOX  Onset Date 3  FORMCHECKBOX  Lab Test Date 5  FORMCHECKBOX  Reported to State or MMWR Report Date 2  FORMCHECKBOX  Diagnosis Type 4  FORMCHECKBOX  Reported to County 9  FORMCHECKBOX  UnknownOutbreak Associated  FORMTEXT __ __ __ (Unknown = 999)Reported  FORMTEXT __ __ / __ __ / __ __ (mm/dd/yy)Imported 1  FORMCHECKBOX  Indigenous 3  FORMCHECKBOX  Out of State 2  FORMCHECKBOX  International 9  FORMCHECKBOX  UnknownCLINICAL DATACOMPLICATIONSClinical ProfileCourse of DiseaseDate of OnsetDuration of Symptoms (Days)SymptomsYNUSymptomsYNU1234567Fever (Max.  FORMTEXT __________ ( F) FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT   Meningitis  FORMTEXT    FORMTEXT    FORMTEXT   Bilateral Parotid Swelling FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT   Deafness FORMTEXT    FORMTEXT    FORMTEXT   Unilateral Parotid Swelling FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT   Orchitis FORMTEXT    FORMTEXT    FORMTEXT   Parotid Tenderness FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT   Encephalitis FORMTEXT    FORMTEXT    FORMTEXT   Malaise FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT   Death FORMTEXT    FORMTEXT    FORMTEXT   Earache FORMTEXT    FORMTEXT    FORMTEXT   /////////////// FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT   Other Complications (If Yes, specify):  FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT   Pain in Jaw (Chewing/Eating) FORMTEXT    FORMTEXT    FORMTEXT   /////////////// FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT   Arthralgia FORMTEXT    FORMTEXT    FORMTEXT   /////////////// FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT   Hospitalized? (If Yes, Days Hospitalized):  FORMTEXT __ __ __ (0-998; 999  Unknown) FORMTEXT    FORMTEXT    FORMTEXT   Other (specify):  FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT   Headache FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT       FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT   LABORATORYWas Laboratory Testing for Mumps Done?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  UnknownDate IgM Specimen Taken  FORMTEXT __ __ / __ __ / __ __ (mm/dd/yy)Result P  FORMCHECKBOX  Positive X  FORMCHECKBOX  Not Done E  FORMCHECKBOX  Pending I  FORMCHECKBOX  Indeterminate N  FORMCHECKBOX  Negative U  FORMCHECKBOX  UnknownDate IgG Acute Specimen Taken  FORMTEXT __ __ / __ __ / __ __ (mm/dd/yy)Date IgG Convalescent Specimen Taken  FORMTEXT __ __ / __ __ / __ __ (mm/dd/yy)Result P  FORMCHECKBOX  Significant Rise in IgG X  FORMCHECKBOX  Not Done N  FORMCHECKBOX  No Significant Rise in IgG E  FORMCHECKBOX  Pending I  FORMCHECKBOX  Indeterminate U  FORMCHECKBOX  UnknownOther Lab Result P  FORMCHECKBOX  Positive X  FORMCHECKBOX  Not Done N  FORMCHECKBOX  Negative E  FORMCHECKBOX  Pending I  FORMCHECKBOX  Indeterminate U  FORMCHECKBOX  UnknownSpecify Other Lab Method  FORMTEXT      VACCINE HISTORYVaccinated? (Received mumps-containing vaccine?)  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  UnknownNumber of doses received ON or AFTER 1st birthday:  FORMTEXT      If not vaccinated, what was the reason? 1  FORMCHECKBOX  Religious Exemption 6  FORMCHECKBOX  Under Age for Vaccination 2  FORMCHECKBOX  Medical Contraindication 7  FORMCHECKBOX  Parental Refusal 3  FORMCHECKBOX  Philosophical Objection 8  FORMCHECKBOX  Other 4  FORMCHECKBOX  Lab Evidence of Previous Disease 9  FORMCHECKBOX  Unknown 5  FORMCHECKBOX  MD Diagnosis of Previous DiseaseVaccination Date (MM/DD/YY)VaccineVaccine Type Code (A=MMR, B=Mumps, O=Other, U=Unknown)Vaccine Manuf. Code (M=Merck, O=Other, U=Unknown)Lot Number FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      EPIDEMIOLOGICDate First Reported to a Health Dept.  FORMTEXT __ __ / __ __ / __ __ (mm/dd/yy)Date Case Investigation Started  FORMTEXT __ __ / __ __ / __ __ (mm/dd/yy)Outbreak Related?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  UnknownIf Yes, Outbreak Name  FORMTEXT      Transmission Setting (Where did this case acquire mumps?) 1  FORMCHECKBOX  Day Care 6  FORMCHECKBOX  Hospital Outpatient Clinic 11  FORMCHECKBOX  Military 2  FORMCHECKBOX  School 7  FORMCHECKBOX  Home 12  FORMCHECKBOX  Correctional Facility 3  FORMCHECKBOX  Doctors Office 8  FORMCHECKBOX  Work 13  FORMCHECKBOX  Church 4  FORMCHECKBOX  Hospital Ward 9  FORMCHECKBOX  Unknown 14  FORMCHECKBOX  International Travel 5  FORMCHECKBOX  Hospital ER 10  FORMCHECKBOX  College 15  FORMCHECKBOX  OtherIf Other, specify Transmission Setting:  FORMTEXT      Were Age and Setting Verified? (Is age appropriate for setting, i.e., aged 49 years and in day care, etc.?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  UnknownSource of Exposure for Current Case:  FORMTEXT      Epi-Linked to Another Confirmed or Probable Case?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  UnknownSTATE USE ONLY!Date Surveillance Rec d at State  FORMTEXT __ __ / __ __ / __ __ (mm/dd/yy)Date Reviewed at State  FORMTEXT __ __ / __ __ / __ __ (mm/dd/yy)Date Sent to CDC.  FORMTEXT __ __ / __ __ / __ __ (mm/dd/yy)CONTACT INFORMATIONPrimary ContactsRelationship To Patient Exposure DateDate of BirthSexTelephone NumberName of School/WorkRe-cent Ill.VaccDis. FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT     FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT     FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT     FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT     FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT     FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT     FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT     FORMTEXT    Clinical Case Definition (1999): An illness with acute onset of unilateral or bilateral tender, self-limited swelling of the parotid or other salivary gland, lasting = 2 days, and without other apparent cause.Case Classification (1999): Probable: a case that meets the clinical case definition, has non-contributory or no serologic or virologic testing, and is not epidemiologically linked to a confirmed or probable case. Confirmed: a case that is laboratory confirmed or that meets the clinical case definition and is epidemiologically linked to a confirmed or probable case. A laboratory-confirmed case does not need to meet the clinical case definition. MUMPS SURVEILLANCE WORKSHEET, Continued IMM-21 JUL 12 IMM-21 JUL 12 Ph    *,@BDNPbdxz|j5CJUjL5CJUj5CJUCJj5CJUmHjb5CJU5CJj5CJUCJjCJUjvCJUjCJU jCJUCJCJCJ5CJ2 EPh*R ($%$$TH40") %$$TH40")`<$$x$$$$ EPh DN| $.2:T^bp $.2\v   D ^ h l $ . 2 ` z        _Rb 2:bp$  ;$$TH4\")($$    "$.0:<PRT^`pr   "$.0\^rtvj5CJUj|5CJUj5CJUj5CJUj5CJUj5CJUj5CJUmHj45CJU5CJj5CJUCJ4 2\ D l `}\;$$TH4\ #)($$;$$TH4\@")   D F Z \ ^ h j " $ . 0 ` b v x z ٵ٩ّٝمj 5CJUj, 5CJUj5CJUj@5CJUj5CJUjT5CJUj5CJU5CJCJj5CJUmHj5CJUjh5CJU4l 2 `   0 x @8$$($;$$TH4\ #)($$       0 2 F H J t v x     . / 0 = > L M N ] ^ l m n j CJUj CJUj( CJUj CJU jCJU6CJj. 5CJU6CJ 5CJmHj 5CJUCJj5CJUmHj 5CJU5CJCJj5CJU2 0 J t x   . / L M [ l m      8 G H I P R a b c }  !"+,8EZ\gr b [  P +H$ . 0$0$$TH4F ) $ ($$n } ~      8 9 G H I R S a b c } ~ jCJUj:CJUjCJUjNCJUjCJUjbCJUjCJUjvCJUjCJUj CJU jCJUCJ5  !",89CDEZ[\fgmqtu!"#ǻ˵DZjCJUjCJUjCJUjCJUj(CJU6CJ 5CJmHj5CJU5CJj5CJUCJjCJUjCJUCJ jCJUj&CJU2+,8\grSThΠ%$$TH40 ) $ $$($0$$TH4F  )!"HISThu}$%FGQR`no '4"&*DHLfpt  a#9:HIJThistu}~$%&78FGHQRnܺܶCJjrCJUjCJUjCJUjCJU6CJjp5CJU6CJ 5CJmHj5CJU5CJj5CJUCJjvCJU jCJUCJ6QR`notc0$$TH4F )$$$%$$TH40)$0$$TH4F ) $  X\$$THt4֞ %'()$$$`~~~~yyyyyyyyy$$$}$$THt4 ` %'()':77$$$TH4d ` h8p%'()$$   !"#'(23  "&(*,@BDHJLNbdfprtvȾ˵ȫ˵ȡ˵}s˵j@CJUj5CJUmHj5CJU5CJj5CJUjXCJUjCJUjCJUmHjpCJUCJ jCJU jCJ5>*CJmHj5>*CJU 5>*CJj5>*CJUCJ-*Lt@bz$$$ 468<>@BVXZ^`bz|jCJUjlCJUjCJUjCJUjCJUjCJUj(CJUCJjCJUmHjCJUCJ jCJU;8<@Z^bz26:TX\vz~ &*.HLPjnr F`dh26:TX\vz~ b.0268:<PRTXZ\^rtvz|~⸴ߓ߉j#CJUj #CJUj"CJUj5CJUmHj$"5CJU5CJj5CJUj!CJUjB\`d~ b:<b?H<<<<7$$$$$TH4d ` h8p%'() (*,0246JLNRTVXlnptvxzپj1CJUj1CJUj0CJUj00CJUj/CJUjH/CJUCJj5CJUmHj.5CJU5CJj5CJUCJjCJUmH jCJUj`.CJU24Vx<^$ 0248:<>RTVZ\pr욖5CJj5CJUj4CJUjD4CJUj3CJUj\3CJUj2CJUjt2CJUj2CJUCJCJjCJUmH jCJU8^`p?<<<<7$$$$$TH4d ` h8p%'() "68:>@BDXZ\`bdfz|~ӶӬӢӘӎӄjX8CJUj7CJUjp7CJUj6CJUj6CJUj6CJUjCJUmHj5CJUCJ jCJUCJj5CJUmHj5CJUj,55CJU4 Bd<^$ 0248:<>RTVZ\pr .02j;CJUj;CJU5CJj;CJUj:CJUj(:CJUj9CJUj@9CJUjCJUmHj8CJUCJCJ jCJU:48<VZ^`p26:TX\vz~4NX\vz~:>\`d   & * H L j n | !2!6!T!X!v!z!!! b^`p?<<<<7$$$$$TH4d ` h8p%'():\~4\~$ 268:<PRTXZ\^rtvz|~46JLNXZ\^rtvz|~쮪j$?CJUj5CJUmHj>5CJU5CJj5CJUj<>CJUj=CJUjT=CJUj<CJUjl<CJUCJCJ jCJUjCJUmH6 "68:>@BDXZ\`bd jBCJUjPBCJUjACJU5CJjhACJUj@CJUj@CJUj @CJUCJjCJUmH jCJUj?CJUCJ; Bd?p<<<<7$$$$$TH4d ` h8p%'() . P r t v x z $     " $ & * , . 0 D F H L N P R f h j n p r !!!.!0!2!6!8!:!& b"""""""?l<<<<7$$$$$THj4d ` h8p%'()""" """$"&"("F""""#"#D#$"""""""""###### #"#$#8#:#<#@#B#h#j#~############################jLCJUjNLCJUjKCJUj5CJUmHjfK5CJU5CJj5CJUjJCJUj~JCJUjCJUmHj JCJUCJ jCJUCJ6CJ4D#F#h#####?<<<<<$$$THj4d ` h8p%'()# $$$$$$ $4$6$8$<$>$@$B$V$X$Z$^$`$b$d$x$z$|$$$$$$$$$$$$$$$$$$$$$$$$$$%ѻαѻΧѻΝѻΓѻΉѻjOCJUjzOCJUjOCJUjNCJUjNCJUjCJUmHjMCJUCJ jCJUCJj5CJUmHj5CJUj6M5CJU5CJ2#$@$b$$$$$ %%%%%$$$ %%%% % %%(%*%>%@%B%F%H%J%L%`%b%d%h%j%l%n%%%%%%%%%%%%%%%%%%%%%%%%%%%%%&ܵjSCJUjRCJUj5CJUmHj2R5CJU5CJj5CJUjQCJUjJQCJUjPCJUCJCJCJjCJUmH jCJUjbPCJU3%%(%J%l%%%?0<<<<7$$$$$TH 4d ` h8p%'()%%%&>&`&&&&&&&$ &&&&&&&2&4&6&:&<&>&@&T&V&X&\&^&`&b&v&x&z&~&&&&&&&&&&&&'''4'6'8'J'L'h'j'l'|'~''''''߷ⴭ⣭♭⏭jVCJUjHVCJUjUCJU jCJUCJ j^UCJUjTCJUjvTCJUjTCJUCJCJjCJUmH jCJUjSCJU5>&X&\&`&z&~&&&&&&&&&&&&''4'6'h'j'''''''(( ('(9(:(W(X(c(v(w(((((((((((( ) )"),)-)R)S)`)u)w)))))))))))***1*2*S*T*^*_*p*************++$+=+J+  a&&&&?0<!$$TH4)$$$TH4d ` h8p%'()&'''''( ('(c((((((")-)R).$0$$TH4F )$  zt  $  zt  ($ $$$'''''(((( (*(+(9(:(;(H(I(W(X(Y(g(h(v(w(x(((((((((((((((((((( ) ) ) )!)"),)R)S)׼ײרמהڑڑjZ5CJUCJ j"ZCJUjYCJUj6YCJUjXCJUjJXCJUjWCJU jCJUCJCJ6CJ 5CJmHj4W5CJU5CJj5CJU4R)S)w))))*^*_*p***$+=+, $  x$  $  z6 0$$TH4F ) $  z  ($ $$$S)T)^)_)`)u)v)w))))))))))))))))))*****"*#*1*2*3*D*E*S*T*U*^*_*s*t********׼ײרמה׊׀j_CJUj^CJUj&^CJUj]CJUj:]CJUj\CJUjN\CJUj[CJU jCJUCJCJ6CJ 5CJmHj8[5CJU5CJj5CJU2***************** + ++++=+>+H+I+, , ,,,0,2,,,,,,,,,,,,,- - ----ĩjbCJUjLbCJUjaCJUCJj5CJUmHj`a5CJU5CJj5CJUj`CJUjt`CJUj_CJUj_CJUCJ jCJU2J+ ,,,0,2,,,,,,,,- --------...8.9.U.f.g...........3/4/>/O/P/s/t//////00040>0B0\0f0j0000000000001 1&10141N1X1\1v111111111111122"2&2@2  a,,0,2,,,,-----U...>/s/Dl $  $<$  $  <$ $$TH4)$$$%$$TH40)-----.....).*.8.9.:.W.X.f.g.h..................../$/%/3/4/5/@/A/O/P/Q/s/t/CJj^gCJUjfCJUjrfCJUjeCJUjeCJUjeCJUjdCJUj$dCJUjcCJUCJjCJUmH jCJUj8cCJU3s/t//////000B0j0000d{{{{{$$F$$TH4r(x!)$$0$$TH(4F()t////////000002040>0@0B0D0X0Z0\0f0h0j0l00000000000000000000000001 1 11"1$1&10121jjCJUj"jCJUjiCJUj6iCJUjhCJUjJhCJUjCJUmHjgCJUCJ jCJU5CJ 56CJ 56CJ5CJ900 141\111111&2N2v2x22223@3B3^3<$$$$F$$TH4r(x!)214161J1L1N1X1Z1\1^1r1t1v11111111111111111111111112222"2$2&2(2<2>2@2J2L2N2P2d2f2h2r2t2x2z22jHnCJUjmCJUj\mCJUjlCJUjplCJUjkCJUjkCJUjCJUmHjkCJU jCJUCJ;@2J2N2h2r2v2x2222222222 33323<3@3B3^3`333333 4L4N4h4444444455&5D5F5Z5555556#6$6B6C6r6s6~6666666666770717:7K7L7o7p77777777777H8b8l8p8r8t8L9j9l99  a22222222222222222222233 33333.30323<3>3B3^3333333333 4L4N4P4d4f4h4444ⷮⷮjq5CJU6CJ 5CJmHj q5CJU5CJj5CJUCJ jpCJUj pCJUjoCJUj4oCJUCJjCJUmH jCJUjnCJU5^3`3333 4L4N44444&5Z555<$ $  ($ $$$$$TH4)4444444444555&5(5D5F5H5`5f5j5z555555555566#6$6%63646B6C6D6c6d6r6s6t66666666÷ǬjuCJUjuCJUjtCJUj$tCJUj5CJUmHjs5CJU5CJj5CJUj8sCJUjrCJUjLrCJU jCJUCJCJ6CJ4556~66:777H8p8r8t8L9Ä l%$$TH40p)` $  <$ $ t $ t ($ ;$$TH4\` ) 6666666666666677777!7"7071727<7=7K7L7M7`7a7o7p7q7}7~7777777777777777777jzCJUj"zCJUjyCJUj6yCJUjxCJUjJxCJUjwCJUj^wCJUjvCJUjrvCJU jCJUjuCJUCJ577778H8J8^8`8b8l8n8p8r8L9N9j9l9n9999999999999F:H:\:^:`:j:l::::::;;.;0;2;L;N;j;l;jH~CJUj}CJUj\}CJUj|5CJUjp|CJUj{CJUj{CJU jCJU5CJj5CJUmHj{5CJU5CJj5CJUCJCJ3999999F:`:j:n::::.;0;j;l;;;;;;;<<<<#<:<G<\<^<i<{<<<<<<<<<<<<<= ==1=>=C=H=I=V= >>(>2>6>P>Z>^>x>>>>>>>>>>>>???8?>?B?\?b?f?h???????????    ^L999F:n::;;;;;;<#<:< {{$$$$$TH4)%$$TH40)$<$%$$TH040p)  $  l;n;;;;;;;;;<<<<<"<:<;<E<F<G<\<]<^<h<{<|<<<<<<<<<<<<<>=C=I=J=T=U=> > >>>$>&>(>2>4>6>8>j5CJUj5CJUmHj5CJU5CJj5CJUj^5CJU6CJ 5CJmHj~5CJU5CJj5CJUCJCJ jCJU8:<^<i<{<<<<<<<<<<<=T~$$TH4)$$$$TH4);$$TH04\h)          <$$$= ==1=>=C=H=I=>6>^>>>>yv$}$$TH4 80h$%')$$$ 8>L>N>P>Z>\>^>`>t>v>x>>>>>>>>>>>>>>>>>>>>>>>>>>?????? ?4?6?8?>?@?B?D?X?Z?\?b?jĄ5CJUjN5CJUj؃5CJUjb5CJUj5CJUjv5CJUj5CJUj5CJUmHj5CJUj5CJU5CJ5>>?B?f?h????@,@T@|@@@|y$}$$TH4 80h$%')$$b?d?h?j?~????????????????????????@@@ @@ @"@(@*@,@.@B@D@F@P@R@T@V@j@l@n@x@z@|@~@@j5CJUj5CJUj5CJUj5CJUj&5CJUj5CJUj5CJUmHj:5CJU5CJj5CJU5?@@"@(@,@F@P@T@n@x@|@@@@@@@@@@@AAA,A6A:ATA^AbA|AAAAAAAAAAAABBB"BDXDbDfDDDDDDDd@@@@@@@@@@@@@@@@@@@@@AAAAAAA(A*A,A6A8A:ADfDD|y$}$$TH4 80h$%')$$BBBBBBBBBC C CC"C$C&C,C.C0C2CFCHCJCTCVCXCZCnCpCrC|C~CCCCCCCCCCCCCCCCCCCCCCCCDj5CJUj"5CJUj5CJUj65CJUj5CJUjJ5CJUjԏ5CJU5CJj5CJUmHj5CJU7DDDDDDD,D.D0D:DD@DTDVDXDbDdDfDhD|D~DDDDDDDDDDDDDDDDDDDDDDDDEEEEEE"E$Eܸܬܠܔ܈jH5CJUjҕ5CJUj\5CJUj5CJUjp5CJUj5CJUj5CJU5CJj5CJUmHj5CJUj5CJU5DDDE&EJEnEpEEEEF4F\FF|y$}$$TH4 80h$%')$$DDDDDDEE"E&E@EFEJEdEjEnEpEEEEEEEEEEFF FF*F0F4FNFXF\FvFFFFFFFFFFFFF GGG4G>GBG\GfGjGGGGGGGGGGGHH H&H*HDHJHNHhHnHrHtHHJ J J)JJKKKKKL L LLLL   `$E&E(EE@EFEHEJELE`EbEdEjElEpErEEEEEEEEEEEEEEEEEEEEEEEFF FFFF&F(F*F0F2F4F6FJFLFj5CJUj5CJUj 5CJUj5CJUj 5CJUj5CJUj45CJUj5CJUmHj5CJUj5CJU5CJ5LFNFXFZF\F^FrFtFvFFFFFFFFFFFFFFFFFFFFFFFFFFG G GGGGG0G2G4G>G@GBGDGXGZG\GfGhGjGlGGj25CJUj5CJUjF5CJUjЛ5CJUjZ5CJUj5CJUjn5CJU5CJj5CJUmHj5CJU7FFFFFGBGjGGGGH*HNHrH|y$}$$TH4 80h$%')$$GGGGGGGGGGGGGGGGGGGGGGGGHHHHHH H&H(H*H,H@HBHDHJHLHNHPHdHfHhHnHpHtH J J)J2JJJKܸܬܠܔܑ6CJCJCJjl5CJUj5CJUj5CJUj 5CJUj5CJUj5CJU5CJj5CJUmHj5CJUj5CJU6rHtHH J J)JJKLzqVzqq$$TH4) ($$}$$TH4 80h$%')KKKKKL L LLLLLL$$$TH$4) KKKKKK L LLLLCJ55CJCJCJ LLL' 0/ =!"#@$%@vDeCheck16vDeCheck17vDeCheck18tDText6vDText22tDText6tDText6tDText7tDText8tDText8vDText16vDText17vDText32vDText31vDText22vDText17vDText32vDText31vDText22vDText17vDText32vDText31vDText22DText15__ __ / __ __ / __ __DText9__ __ __vDeCheck19vDeCheck21vDeCheck23vDeCheck20vDeCheck22vDeCheck19vDeCheck20vDeCheck21vDeCheck19vDeCheck21vDeCheck19vDeCheck26vDeCheck24vDeCheck25vDeCheck27vDeCheck28vDeCheck29DText15__ __ / __ __ / __ __vDeCheck19vDeCheck23vDeCheck30vDeCheck20vDeCheck31vDeCheck32DText9__ __ __DText15__ __ / __ __ / __ __vDeCheck19vDeCheck21vDeCheck20vDeCheck22DText1 __________tDText3tDText3tDText3tDText5tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText5tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText5tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText5tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText5tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText2tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3zD__ __ __tDText3tDText3tDText3tDText2tDText3tDText3tDText3tDText5tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText3tDText5tDText3tDText3tDText3tDText3tDText3tDText3tDText3vDeCheck33vDeCheck34vDeCheck35DText15__ __ / __ __ / __ __vDeCheck19vDeCheck21vDeCheck20vDeCheck38vDeCheck36vDeCheck37DText15__ __ / __ __ / __ __DText15__ __ / __ __ / __ __vDeCheck19vDeCheck21vDeCheck20vDeCheck39vDeCheck38vDeCheck37vDeCheck19vDeCheck21vDeCheck20vDeCheck38vDeCheck36vDeCheck37vDText62vDeCheck40vDeCheck41vDeCheck42vDText68vDeCheck43vDeCheck48vDeCheck44vDeCheck49vDeCheck45vDeCheck50vDeCheck46vDeCheck51vDeCheck47vDText63vDText64vDText65vDText66vDText67vDText63vDText64vDText65vDText66vDText67vDText63vDText64vDText65vDText66vDText67vDText63vDText64vDText65vDText66vDText67DText15__ __ / __ __ / __ __DText15__ __ / __ __ / __ __vDeCheck40vDeCheck41vDeCheck42vDText69vDeCheck43vDeCheck48vDeCheck53vDeCheck44vDeCheck49vDeCheck54vDeCheck45vDeCheck50vDeCheck55vDeCheck46vDeCheck51vDeCheck56vDeCheck47vDeCheck52vDeCheck57vDText70vDeCheck40vDeCheck41vDeCheck42vDText71vDeCheck40vDeCheck41vDeCheck42DText15__ __ / __ __ / __ __DText15__ __ / __ __ / __ __DText15__ __ / __ __ / __ __vDText50vDText51vDText52vDText53vDText54vDText55vDText56vDText72vDText72vDText72vDText50vDText51vDText52vDText53vDText54vDText55vDText56vDText72vDText72vDText72vDText50vDText51vDText52vDText53vDText54vDText55vDText56vDText72vDText72vDText72vDText50vDText51vDText52vDText53vDText54vDText55vDText56vDText72vDText72vDText72vDText50vDText51vDText52vDText53vDText54vDText55vDText56vDText72vDText72vDText72vDText50vDText51vDText52vDText53vDText54vDText55vDText56vDText72vDText72vDText72vDText50vDText51vDText52vDText53vDText54vDText55vDText56vDText72vDText72vDText72 [,@,Normal OJQJmH 8@8 Heading 1 $$@&5CJ<< Heading 2$$x@&5CJ8@8 Heading 3 $$@&5CJ4@4 Heading 4 $$@&58@8 Heading 5 $$@&5CJ8@8 Heading 6 $$@&5CJ<A@<Default Paragraph Font,@,Header  !, @,Footer  !* 6 ))88GJ n #fr2 b?@ABD$ELFGKL.2469:=BDFIKMPRTVZ[^aegilprsvxz|~Rl + :^^z !""D##%%&&R),s/0^35L9:<=>@BDFrHKL/1358;>?@ACGHJLOQSUXY\]_`cdfhjknoquwy} !>&J+@29?DLL07<ENWbmt{ #/5?KQVbhz%<HN^jp%>JPcou -=K[k{#FV`p/FRh  0GWv#3EU # . 5 A D F R U W c f h t z |     ! - 0 N Z ] _ k n p |    ! $ & 2 5 7 C F e q t v     ! , 8 ; = I L N Z ] s     , / > J M O [ ^ ` l o z "%'36>JMO[^`loz !#/2\hnp|!$&257CFHTWYehjvy !#/24@C '*,8;=IOQ]`bnqs ),.:=?KNP\_ampr~3?Ul|@Lb (GWdt *:L\O[a 5Eaq{ $&28:FLNZ`couw$*co /O[a )9CSm} 2BScp2 B Q a o  !!$!2!B!!!!!!!"")"""""""" ######%#1#5#7#C#I#K#W#]#_#k#o#q#}#####################$ $ $$$ $,$0$2$>$B$D$P$T$W$c$i$k$w$}$$$$$$$$$$$$$$$$$$$$$%%%%%$%*%,%8%>%@%L%R%T%`%f%h%t%x%z%%%%%%%%%%%%%%%%%%%%%& &&&!&'&)&5&9&;&G&M&O&[&a&c&o&s&u&&&&&&&&&&&&&&&&&&&&&&''''"'$'0'4'6'B'F'H'T'X'['g'm'o'{'''''''''''''''''''''(( (((*G$G$G$FTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTG G G G$G$G G$G G G G$G$G$G$G$G$G$FTG G G G$G$G$FTFTG G G$G$FTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTFTG$G$G$FTG$G$G$G$G$G$FTFTG$G$G$G$G$G$G$G$G$G$G$G$FTG$G$G$FtG G G$G$G$G$G$G$G$FtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFtFTFTG$G$G$FtG G G G$G$G G$G$G$G$G$G$G$G$G$FtG$G$G$FtG$G$G$FTFTFTFTFTFTFTFTFTFTFtFtFtFTFTFTFTFTFTFTFtFtFtFTFTFTFTFTFTFTFtFtFtFTFTFTFTFTFTFTFtFtFtFTFTFTFTFTFTFTFtFtFtFTFTFTFTFTFTFTFtFtFtFTFTFTFTFTFTFTFtFtFtHCheck16Check17Check18Text22Text7Text16Text17Text32Text31Text15Text9Check19Check21Check23Check20Check22Check26Check24Check25Check27Check28Check29Check30Check31Check32Text1Text3Text5Text2Check33Check34Check35Check38Check36Check37Check39Text62Check40Check41Check42Text68Check43Check48Check44Check49Check45Check50Check46Check51Check47Text63Text64Text65Text66Text67Text69Check53Check54Check55Check56Check52Check57Text70Text71Text50Text51Text52Text53Text54Text55Text56Text72${=.Ll !H 6 i HP6b|PD Tq """#&#8#L#`#+  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFG6&O>\|01X/ E { Xb!FrbTd ""#$#6#J#^#p#+7<npqs# + "[]^`&)hjkmtwAD7<>EGNPYchpwy-: q!v!!!!!!!!!""/"1"2"4"""""**+  **+ewhiteFC:\DOCUME~1\EWHITE~1.NJD\LOCALS~1\Temp\AutoRecovery save of IMM-21.asdewhiteFC:\DOCUME~1\EWHITE~1.NJD\LOCALS~1\Temp\AutoRecovery save of IMM-21.asdewhiteFC:\DOCUME~1\EWHITE~1.NJD\LOCALS~1\Temp\AutoRecovery save of IMM-21.asdewhiteFC:\DOCUME~1\EWHITE~1.NJD\LOCALS~1\Temp\AutoRecovery save of IMM-21.asdewhite+\\dhss-cap-103\home\ewhite\FORMS\IMM-21.dotewhite+\\dhss-cap-103\home\ewhite\FORMS\IMM-21.dotewhite+\\dhss-cap-103\home\ewhite\FORMS\IMM-21.dotewhiteNC:\DOCUME~1\EWHITE~1.NJD\LOCALS~1\Temp\AutoRecovery save of IMM-21 (NJDOH).asdewhiteNC:\DOCUME~1\EWHITE~1.NJD\LOCALS~1\Temp\AutoRecovery save of IMM-21 (NJDOH).asdewhite1\\dhss-ha-99\home\ewhite\FORMS\IMM-21 (NJDOH).dot@ 7{lB B B B B BBBBBB !"$%&(*@ @ $&P@,\@024l@8:x@>BDF@G:Times New Roman5Symbol3& :Arial"qhʱuZgtZg -7#Kٖ4!20d?+!IMM-21, Mumps Surveillance RecordVIMM-21, mumps, surveillance, vaccine preventable diseases, VPDP, immunization, vaccineewhiteewhiteOh+'0HTp     "IMM-21, Mumps Surveillance RecordosMM-ewhite WIMM-21, mumps, surveillance, vaccine preventable diseases, VPDP, immunization, vaccineMM-IMM-21 (NJDOH).doteewhite(13iMicrosoft Word 8.0e@|{6@Wl_@&zx@@F{l_-7#՜.+,D՜.+,P  hp  NJDOH K?+1 "IMM-21, Mumps Surveillance Record Title 6> _PID_GUIDAN{C456CF7C-C71F-4FFF-B1F6-E59E8652AD20}  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~     Root Entry Fr4pl_Data 1TableO1WordDocument)6SummaryInformation(DocumentSummaryInformation8CompObjjObjectPoolpl_pl_  FMicrosoft Word Document MSWordDocWord.Document.89q