Technical Guidelines for Integrated Disease Surveillance ... - PHRplus

To be completed by the health facility:Instructions for completing line list form1. Complete the name of the health facility and sub-district by submitting the form. Record the name of thesub-district, district and region that is receiving the report.2. Indicate the date the form is completed.3. Record the disease or condition which is being reported. If the disease or condition is not stated, or itscause is unknown, write “unknown” in the field for “Disease/Condition”.To be completed by the district:4. Record the date that the line list is received at the district level.5. Assign and record the unique identification number (ID number) for the case. The ID number shouldhave 11 fields as follows:The first 3 letters should represent the unique regional codeThe second 3 letters should represent the unique district codeThe third 2 numbers should represent the year of reportingThe last 3 numbers should represent the numerical position of that particular case for a specificdisease for the year of reporting.For example, if the last time a case of meningitis was reported in Dangme West District was December2000, and it was the 30 th case in that year, it would be have the number GAR-DAW-00-030. A first caseof meningitis reported in the year 2001 will have the number GAR-DAW-01-001. On the other hand ifthe last time a case was reported was January 2001, and it was the 30 th case since the first of the year, itwould be reported in February 2001 as GAR-DAW-01-031. In other words, for every disease, numberingstarts from 001 at each New Year.6. Record whether the patient is an inpatient or outpatient at the time the case is reported by indicating “I”for inpatient and “O” for outpatient.7. Record the name of the patient.8. Record information about the patient’s place of residence. Include the name of the sub-district and thecommunity/town/suburb where the patient lives.9. Record “M” for Male, and “F” for Female.10. Record the patient’s age in years, or in months if the patient is less than 12 months old.11. Record the date the patient is seen at the health facility.12. Record the date of onset of the disease.Annex 9: Line List for Reporting Case-based Information When Several Cases Occur During a Short Period151