Technical Guidelines for Integrated Disease Surveillance ... - PHRplus

Case-based surveillance reporting form(from health facility/worker to district health team and laboratory)1. District Case ID No.:2. _____________________ ____________________ ____________________ ____________________Reporting Health Facility Sub-district District Region3. Disease: Cholera Diarrhea with Measles Meningitis Viral Yellow ______________Blood/Shigella Hemorrhagic Fever Fever Other4. Name of 5. Date of Age:patient: _________________________ birth: _____/______/______ (If DOB_____years______monthsunknown)6. Sex: M=Male F=Female7. Patient’s residence: Community/Sub-district _______________________ Urban/Rural: U=Urban R=RuralTown/City: ______________________________District ofresidence: _______________________________8. Locating information:_________________________________________________________________(If applicable, name of mother and father if neonate or child/landlord)(For cases of measles, yellow fever, and meningitis)9. Date seen at health facility: ______/_______/______ 12. Number of vaccine doses received(For measles, YF–documented by card.10. Date health facilitynotified district:______/_______/______For meningitis, by history.)9=unknown11. Date of onset: ______/_______/______ Date of last vaccination: ______/_______/______(measles, yellow fever, and meningitis only)Additional variable______________________ 13. In/Outpatient: 1=Inpatient 14. Outcome: 1=Alive2=Outpatient 2=DeadAdditional variable ___________________________________________ 9= unknown15. Person completing Name: ___________________________formSignature: ________________________Date sent form to district:_____/______/_____Date: ____________________________16. Final classification: 1=Confirmed (Lab test Pos)(To be completed by district)2=Discarded (Lab test Neg.)3=Suspected (Lab test Not Done)144Technical Guidelines for Integrated Disease Surveillance and Response in Ghana