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Technical Guidelines for Integrated Disease Surveillance ... - PHRplus

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SPECIMEN COLLECTIONDate Sent toDate 1 st Stool: ____/____/_____ Date 2 nd Stool: ____/____/_____ National lab: ____/____/_____STOOL SPECIMEN RESULTS: Condition of Stool: 1=Adequate, 2= Not Adequate_____/_____/_____ _____/_____/_____ _____/_____/_____Date received by national Lab Date results sent by lab to district Date results receive by district_____/_____/_____ _____/_____/_____ _____/_____/_____Date isolate sent by Date differentiation result Date differentiation resultnational Lab to regional lab sent by regional lab received by districtPrimary Isolation Results: P1 P2 P3 NP-Ent W1 W2 W3 V1 V2 V3 NP-EntFOLLOW UP EXAMINATIONDate of follow up examination: _____/_____/_____ Residual paralysis? Findings at follow-up: LA RA 1= Residual paralysisLL RL 2= No residual paralysis3= Lost to follow-up4= Death be<strong>for</strong>e follow-upFINAL CLASSIFICATION OF THE CASE: 1=Confirmed, 2=Compatible, 3= Discarded 6=Not AFPINVESTIGATORName: ______________________________________ Title: _______________________________________Unit: __________________ Address: ________________________________ Phone: ___________________184<strong>Technical</strong> <strong>Guidelines</strong> <strong>for</strong> <strong>Integrated</strong> <strong>Disease</strong> <strong>Surveillance</strong> and Response in Ghana

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