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Technical Guidelines for Integrated Disease Surveillance ... - PHRplus

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Annex 10Weekly Notifiable <strong>Disease</strong> Report FormHealth facility: _____________ Sub-district: ____________ District: ____________ Region: ____________Week beginning Sunday ______/______/________Week ending Saturday ______/______/________ Year: ______________________Reporting site(Health Facility/District/Region)Cases*CHOLERADeathsCases*MEASLESDeathsCases*MENINGITISDeathsTotal* Report zero (0) when no cases of disease are seen in reporting period.Name of person reporting: _______________________________________Signature: _____________________________________________________Date: ______/______/_______Annex 10: Weekly Notifiable <strong>Disease</strong> Report Form153

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