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Technical Guidelines for Integrated Disease Surveillance ... - PHRplus

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Annex 16Quarterly Report on New and Recurrent Cases ofBuruli Ulcer (BU 03)Buruli ulcerPatients registered during ___Qtr of _____Name of district: _________________________ Number of district: ______________________________Name of officer completing this <strong>for</strong>m:_______________________________________________________Title:___________________________________Date of completion of this <strong>for</strong>m (dd/mm/yy): ___/___/___Address:_____________________________________________________________________________________________________________________________________________________________________Tel:______________________________________Fax:________________________________________Email: _______________________________________________________________________________1. New and recurrent casesNewRecurrentLaboratory confirmation No laboratory confirmation Sub-total Total49 yrs 49 yrsM F M F M F M F M F M F M F M F2. Clinical <strong>for</strong>ms of new and recurrent casesNodulePapule Plaque Oedema Ulcer Osteomyelitis Mixed TotalNewRecurrent3. Disabilities in new and recurrent casesYesDisability presentNoTotalNewRecurrentAnnex 16: Quarterly Report on New and Recurrent Cases of Buruli Ulcer (BU 03)169

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