Current Form

MALARIA CASE SURVEILLANCE REPORT
Department of Health and Human Services, Centers for Disease Control and Prevention
Division of Parasitic Diseases (MS F-22), 4770 Buford Highway, N.E.
Atlanta, Georgia 30341

State Case No: .......................
DASH No:
.......................
Patient name (last, first):

Case No: .........................
Form Approved
County: .........................
OMB 0920-0009
Age (yrs): ______ (mos): ______
Sex:
~ Male
Date of Birth: ____/ ____/ ________
~ Female
Date of symptom onset of this attack (mm/dd/yyyy): ____/ ____/ _____ Is patient pregnant? ~ Yes
~ No
Physician name (last, first):
Ethnicity:
Race (select one or more):
~ Hispanic or Latino ~ American Indian or Alaska Native
~ Not Hispanic or
~ Native Hawaiian or Other Pacific
Telephone Number: (
) _________ – ___________
Latino
Islander
~ Black or African American
~ Asian ~ White ~ Unknown
Lab results:
State/territory reporting this case: ___________________
~ Smear positive ~ Smear Negative ~ No Smear Taken
~ No
Patient admitted to hospital: ~ Yes
Species (check all that apply):
Hospital: _______________________________________
~ Vivax ~ Falciparum ~ Malariae ~ Ovale ~ Not Determined Date: ____/ ____/ ________ Hospital record No.: ________
Laboratory name:
Specimens being sent to CDC? ~ Yes
~ No
Telephone Number: (
) _________ – ___________
If yes: ~ Smears ~ Whole Blood ~ Other: ___________
Has the patient traveled or lived outside the U.S. during the past 4 years? ~ Yes
~ No
If yes, specify:
Country:
1. ________________
2. _________________
3. ___________________
Date returned/ arrived in U.S. (mm/dd/yyyy):
____/ ____/ ______
____/ ____/ ________
____/ ____/ ________
Duration of stay in foreign country (days):
_________________
__________________
___________________
Did patient reside in U.S. prior to most recent travel?
Principal reason for travel from/ to U.S. for most recent trip:

~ Yes, for ≥12 months
~ Tourism
~ Visiting friends/relatives ~ Student/teacher
~ Yes, for <12 months
~ Military
~ Airline/ship crew
~ Other: __________
~ No, (specify country): _____________________
~ Business
~ Missionary or dependent
~ Unknown
~ Peace Corps ~ Refugee/immigrant
Was malaria chemoprophylaxis taken? ~ Yes
~ No
If yes, which drugs were taken?
~ Chloroquine ~ Mefloquine
~ Doxycycline
~ Primaquine
~ Malarone®
~ Other: _______________
Were all pills taken as prescribed?
~ Yes, missed no doses
~ No, missed one to a few doses
~ No, missed more than a few but < half of the doses
~ No, missed half or more of the doses
~ No, missed doses but not sure how many
~ Don’t know

If doses were missed, what was the reason?
~ Forgot
~ Didn’t think needed
~ Had a side effect (specify): ________________________________
~ Was advised by others to stop
~ Prematurely stopped taking once home
~ Other (specify): _________________________________________

History of malaria in last 12 months (prior to this report)? ~ Yes
~ Falciparum
If yes, species (check all that apply): ~ Vivax

~ No
~ Malariae

Date of previous illness: ____/ ____/ ________
~ Ovale
~ Not Determined

Blood transfusion/organ transplant within last 12 months: ~ Yes ~ No
If yes, date: ____/ ____/ ________
Cerebral malaria
ARDS
None
Was illness fatal:
Yes
No
Unknown
Clinical
complications
Renal failure
Anemia
Other : ___________
If yes, date of death : _____/____/_________
for this attack:
(Hb<11, Hct<33)
Therapy for this attack (check all that apply):
Chloroquine
Primaquine

Tetracycline/doxycycline
Quinine/quinidine

Mefloquine
Pyrimethamine-sulfadoxine

Person submitting report: ____________________________________
Affiliation:
___________________________________
For CDC Use Only.
Classification
Imported
Induced

Exchange transfusion
Malarone

Unknown
Other (specify): ____________

Telephone No. : __________________________________
Date:
__________/__________/_____________
Introduced
Congenital
Cryptic

Public reporting burden of this collection of information is estimated to average 15 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. Please send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Rd., NE (MS D-24); Atlanta, GA 30333; ATTN: PRA (0920-0009).

CDC 54.1 01/2002 (Front)

If sending specimens, please forward blood smears (thick and thin) with this report.

Physicians and other health care providers with questions about diagnosis and treatment of malaria
cases can call CDC’s Malaria Hotline:
- Monday – Friday, 8:00 am to 4:30 pm, EST: call 770-488-7788 (Fax: 770-488-4206)
- Off-hours, weekends, and federal holidays: call 770-488-7100 and ask to have the malaria
clinician on call paged.
Information on malaria risk, prevention, and treatment is available at:
- CDC’s Travelers’ Health Web site http://www.cdc.gov/travel
- CDC’s Travelers’ Health Information Service: call 1-877-FYI-TRIP
- CDC’s Malaria Web site http://www.cdc.gov/malaria
Health Information for International Travel is available from the Public Health Foundation:
Call 1-877-252-1200, or order on line at http://www.phf.org

CDC 54.1 01/2002 (FRONT) If sending specimens, please forward blood smears (thick and thin) with this report.