2022 U.S. monkeypox outbreak short case report form
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2022 U.S. monkeypox outbreak short case report form

Filetype[PDF-748.77 KB]


  • Description:
    Form Approved

    OMB No. 0920-1011

    Exp. Date 01/31/2023

    Short Case Report Form 2022 Monkeypox Outbreak

    Sensitive but Unclassified

    Instructions for State, Local, and Territorial Health Jurisdictions: This form is an aid for public health officials when collecting essential data elements needed for investigating and reporting probable or confirmed monkeypox cases to CDC as part of the 2022 U.S. Monkeypox Outbreak response. Local public health officials may choose to use this fillable PDF for data collection within their jurisdiction, but data submission to CDC should be through established case surveillance systems and not through individually completed forms. Case information should always be captured electronically to minimize transcription errors; however, this form may be printed if needed.

    Note: This form is to be administered to the patient or their proxy–if the patient is deceased, administer with their proxy and/or healthcare provider.


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