Technical Guidelines for Integrated Disease Surveillance ... - PHRplus

Annex 14Cased-based Surveillance Report Form for BuruliUlcer (BU01)A copy of this form should be kept in the patient’s record at the health facility where treatment is provided.A. Institutional Information1. Name of institution, address: _________________________________________________2. Sub-district: ___________District: _____________Region: ______________Country:________________3. Name of officer completing this form (Last/ First):_____________________________________________4. Title: ___________________________________ Specialization: ________________________________B. Patient Information5. Health facility ID #:__________________________________ Date of admission(dd/mm/yy):___/___/___6. Name (Last/First): ______________________________ 7. Age: |__|__|years 8. Sex: M F9. Address/Village:________________________________________________________________________10. Sub-district: ______________District:_____________Region:____________Country:_______________11. Occupation of patient: Student Farmer Other, specify:___________________________12. Source of drinking water: Pipe-borne Borehole/well River/stream Pond/stagnant13. Patient classification:New caseRecurrence: same site different site Date of last treatment(dd/mm/yy) __/__/__14. Duration of illness before seeking care: |__|__| weeks |__|__| months15. Use of traditional treatment N Y16. History of cases in family/among relatives: N Y17. History of trauma at site of lesion: N Y18. BCG vaccination or scar: N YAnnex 14: Case-based Surveillance Report Form for Buruli Ulcer (BU01)161