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Technical Guidelines for Integrated Disease Surveillance ... - PHRplus

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G. Treatment Outcomes25. Healed without sequelaeHealed with sequelae, specify:_______________________________________________________Referral <strong>for</strong> treatment of active lesions: where__________________Date: (dd/mm/yy)___/___/___Absconded/discharged against medical adviceDied, Buruli ulcer related, specify:___________________________________________________Died, not related to Buruli ulcer, specify:______________________________________________H. Referral of Sequelae26. No: why not___________________________________________________________________Yes: where____________________________________________when (dd/mm/yy)___/___/____27. Date of Discharge (dd/mm/yy):___/___/___Annex 14: Case-based <strong>Surveillance</strong> Report Form <strong>for</strong> Buruli Ulcer (BU01)163

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