Technical Guidelines for Integrated Disease Surveillance ... - PHRplus

Instructions for completing case-based surveillance report formTo be completed by the district (items 1 and 16) and health facility (items 2-15, also items 17-18 if laboratoryspecimen collected):1. Record the unique identification number (ID number) for the case in the field for “ID number”.2. Complete the name of the health facility submitting the case-based reporting form. Record the name of thedistrict and region that is receiving the report.3. Tick the box at the top of the form to indicate which disease is being reported. If the disease or condition is notstated, or its cause is unknown, write the name of the disease or condition (or “unknown”) in the blank marked“Other”.4. Record the name of the patient.5. Record the patient’s date of birth; if exact date of birth is not known, record the patient’s age.6. Record “M” for Male, and “F” for Female.7. Record information about the patient’s residence. Include the name of the community or neighborhood wherethe patient lives. Also include the name of the sub-district and district where the patient lives.8. Record information about how to contact the patient or the patient’s parents for use at a later time whenadditional information about the patient’s illness may be needed.9. Record the date the patient was seen at the health facility.10. Record the date the health facility reported the disease or condition to the district.11. Record the date of onset of the disease, if known.12. For vaccine-preventable diseases such as measles, meningitis and yellow fever, obtain the patient’s immunizationhistory for the reported illness. Record the number of vaccine doses received by the patient for that illnessand the date of the last immunization dose. Do not count doses that were received within the last 15 days. If theimmunization was received within the last 15 days, there may not have been an immunization response.For meningitis, record if there is a history of vaccination during a mass campaign.13. Report whether the patient was an outpatient or inpatient at the time the case was reported.14. Record whether the patient was living or deceased at the time the report was made. If the patient’s illness isreported and the patient later dies, inform the district. The district can change the status on the form.15. The health facility staff member who completes the form should sign his or her name, the date the form wasfilled and also the date the form was sent to the district.146Technical Guidelines for Integrated Disease Surveillance and Response in Ghana