Case Report Form
Rotavirus Surveillance
I. INFORMATION ABOUT THE DISEASE REPORTING UNIT (RDU)
Name of DRU:
Address:
Type:
Government
Private
Contact Number:
II. PATIENT INFORMATION
Find
Patient Number:
EPI ID:
Patient's Last Name
First Name:
Middle Name:
Current Address:
Permanent Address:
Sex:
Male
Female
Is patient enrolled in 4P's (National Household Targeting System?:
Yes
No
Date of Birth:
Is the case a member of Indigenous Group?:
Yes
No
If Yes, specify:
Age:
Days
Months
Years
District:
ILHZ:
Region:
Healthcare provider network/SDN:
III. CLINICAL DATA (Put a check in the appropriate box)
IV. EPIDEMIOLOGY
IV. IMMUNIZATION HISTORY
VI. DETAILS OF INVESTIGATIOR/REPORTING
Date onset of Diarrhea:
Was patient admitted at the wards for diarrhea?:
Yes
No
If yes, date of admission:
Did patient receive IV rehydration therapy while at the ER?
Yes
No
Did patient have previous hospitalization due to diarrhea?
Yes
No
If yes, date of hospitalization:
Are there two or more diarrhea cases?
Yes
If Yes, where:
Community
School
Household
No
Unknown
Received Rotavirus Vaccine?
Yes
No
If Yes, total doses received:
Date first dose received :
Date last dose received :
Name of Investigator:
Position/Designation:
Contact Number:
Date of Investigation:
Date of report:
Vomiting?:
Yes
No
If yes, date of onset of vomiting
Degree of Dehydration:
No dehydration
Some dehydration
Severe dehydration
Fever?:
Yes
No
ADMITTING:
DIAGNOSIS:
FINAL DIAGNOSIS:
VII. LABORATORY DATA
VIII. CLASSIFICATION AND OUTCOME
STOOL SPECIMEN
SPECIMEN CONDITION AND ADEQUACY
(To be filled out by RITM)
ELISA RESULT
(To be filled out by RITM)
PCR RESULT
(To be filled out by RITM)
*Stool Collected
Yes
No
If YES, date taken:
Date sent to RITM:
Date Received by RITM:
Condition:
Frozen
Thawed but cold
Warm
Number of icepack:
Quality of Stool:
Sufficient
Sufficient for ELISA but no remaining sample
Insufficient
NEG
POS
Equivocal
Date of result:
Genotype:
Date of result:
Classification:
Suspected
Yes
No
Confirmed
Yes
No
Outcome:
Alive
Date of Discharge:
Died
Date of Death:
CASE DEFINITION AND CLASSIFICATION:
Suspected Case:
Acute (<14 days) watery diarrhea, defined as three or more loose or watery stools in 24-hour period in a child < 5 years of age who is admitted for treatment of diarrhea to a hospital ward or emergency unit at a participating surveillance facility. Children with bloody diarrhea and nosocomial infractions are excluded.
Confirmed Case:
A suspected case in who stool the presence of rotavirus is demonstrated by means of an anti-gen enzymes immunoassay (EIA) or any molecular diagnostic test.
Deliberately providing false or misleading, personal information on the part of the patient, or the next kin incase of patient's incapacity, may constitute non-cooperation punishable under the Republic Act No. 11332
Attach File
SUBMIT
PRINT
BACK
Patients
Search
Patient ID
Patient Name
Gender
Blood Group
Age
