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CDC 55.54 Kawasaki Syndrome Case Report Form

CDC 55.54 is the national surveillance case report for Kawasaki syndrome. A treating pediatrician or cardiologist meets it when a child's case is reported, often through a state health department; Maryland's health department lists it with its case report forms. It captures the clinical criteria, cardiac study results, complications and intravenous gamma globulin (IVGG) treatment, and is mailed to CDC's Kawasaki Syndrome Surveillance program.

Who completes it

The treating physician or the health department completes the whole one-page form and fills in the Reported By block with name, address, phone and date. The CDC case number box at the top is left for CDC.

Submitting and payment

How to submit it
Mail the completed form to Kawasaki Syndrome Surveillance at CDC, as printed on the form, or send it through your state health department where Kawasaki syndrome is reportable.
Who pays
CDC lists no fee or payment for completing the report.

Good to know

  • The printed case definition requires fever of 5 days or more unresponsive to antibiotics plus four of five findings: bilateral conjunctival injection, oral changes, extremity changes, rash and cervical lymphadenopathy over 1.5 cm.
  • If IVGG ends the fever before the fifth day of illness, the shorter fever still meets the criterion, and the form asks whether IVGG started before day 5 while febrile.
  • For EKG, echocardiogram and angiogram, record whether coronary aneurysm or dilatation was found, the weeks after onset, and the date of the first study showing it.
  • The form asks about recurrent Kawasaki syndrome with the prior episode's onset date, and lists complications such as aortic regurgitation, myocarditis, gallbladder hydrops and uveitis.

Get the official form

Download the current version from the source each time; forms change without notice.

Kawasaki Syndrome Case Report

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who sends the Kawasaki syndrome case report to CDC?

Either the treating physician or the health department. The form prints the mailing address of CDC's Kawasaki Syndrome Surveillance program, and some state health departments, including Maryland's, post it with their own case report forms. Where Kawasaki syndrome is reportable, the state health department collects the report first.

What cardiac information does CDC 55.54 ask for?

For each of EKG, echocardiogram and angiogram, mark not done, normal, coronary artery aneurysm, dilatation, other abnormality or unknown, with the weeks after onset the study was done. If several studies were done, report the one that first showed aneurysm or dilatation, and give the aneurysm diameter in millimeters under complications.

Is CDC 55.54 a fillable form?

Yes. CDC posts a one-page fillable PDF: the June 2003 form, CDC 55.54 (E), in an accessible electronic version from October 2011, approved under OMB 0920-0009. CDC estimates about 15 minutes to complete it, including reviewing the instructions and gathering the data.