Technical Guidelines for Integrated Disease Surveillance ... - PHRplus

Annex 21Case Investigation Form – Neonatal TetanusOfficial Use Epid Number: ______-______-______-______ ReceivedOnly (completed by district team) Region District Year Onset Case Number at National _____/_____/_____IDENTIFICATIONDistrict: ____________________________Region: _____________________________Nearest health Village/ Town/facility to village: _________________ Suburb: __________________ City: ___________________Address:_________________________________________________________________________________________________________________________________________________________________________________________________Name of patient: _______________________________Mother: _______________________Sex: 1 = Male, 2 = Female Father: ________________________NOTIFICATION/INVESTIGATIONNotified Date Date caseby: ______________________ notified: _______/_______/______ investigated: ______/______/______MOTHER’S VACCINATION HISTORY Please use the following key, 1=Y, 2=N, 9=U, where applicable.QuestionAnswerMother vaccinated with TT? 1 st ____/____/____ 4 th ____/____/____Have card? 2 nd ____/____/____ 5 th ____/____/____Number of doses:3 rd ____/____/____ If >5, last dose_____/_____/____Vaccination status of motherprior to delivery? ****1= up-to-date, 2= not up-to-date, 9= unknownBIRTH OF INFANTDate of birth: ______/______/______Please use the following key, 1=Y, 2=N, 9=U, where applicable.Questions Answer Questions AnswerMother received antenatal care? Location of birth: ***How many prenatal visits? If birth in institution,Attended by a trained TBA/ name of institution:midwife? Cut cord with a sterile blade?If attended by a trained TBA/ Cord treated with anything?midwife, give name Describe treatment of cord:Attended by doctor/nurse? Where?*** 1=Hospital, 2=Health center, 3=Home, trained attendant, 4=Home, untrained attendant, 5=Home, no attendant, 9=UnknownAnnex 21: Case Investigation Form - Neonatal Tetanus181