Assessment for Health Facilities

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (NCIRD)

Attachment B_Ebola_Malaria_Assessment_Health Facility

Management of Fever in Travelers from Ebola Affected and Ebola Non-affected Malaria Endemic Countries

OMB: 0920-1026

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Shape3 Shape4 Shape2

Approved Form

OMB No. 0920-1026

Exp. Date: 07/31/2017


EBOLA / MALARIA ASSESSMENT

Shape5

OMB Approved

0920-XXXX

Expiration Date xx/xx/xxxx

CDC Assigned ID: ....................... State/territory reporting this case: ..................................... Case No: .........................


Patient name (last, first):


Date of symptom onset of this attack (mm/dd/yyyy): ____/ ____/ _____

Age: _______ yrs. mos. wks. days (circle units)

Date of Birth: ____/ ____/ ________

Sex: Male Female Unknown

Physician name (last, first):



Telephone Number: ( ) _________ – ___________

Ethnicity:

Hispanic or Latino

Not Hispanic or Latino

Unknown

Race (select one or more):

American Indian/Alaska Native

Native Hawaiian/Other Pacific Islander

Black or African American

Asian White Unknown


Symptom History

Yes

No

When did the
fever start?

When did the patient first seek medical attention:

Date: ____/ ____/ ________

Patient admitted to hospital:

Yes No Unknown


Hospital: _______________________________________


Date: ____/ ____/ ________ Hospital record No.: ________


Was the patient admitted to the ICU:

Yes No Unknown


Date: ____/ ____/ ________


Initial diagnosis: ____________________ (ICD-9 code)


Final diagnosis: ____________________ (ICD-9 code)


Is the patient insured? Yes No Unknown






Fever

____/ ____/ ________

Nausea


Vomiting


Diarrhea


Upper respiratory symptoms (cough, congestion)


Rash


Altered mental status


Jaundice







Laboratory Tests


Yes

No

Unknown

Date and time test done

mm/dd/yyyy hh:mm

Results

Date and time results available mm/dd/yyyy hh:mm

CBC

___/___/______

__ __ : __ __

am

pm

N/A

___/___/______

__ __ : __ __

am

pm

Chemistry panel

___/___/______

__ __ : __ __

am

pm

N/A

___/___/______

__ __ : __ __

am

pm












Tested for malaria?

___/___/______

__ __ : __ __

am

pm





Microscopy
Thin Smear

___/___/______

__ __ : __ __

am

pm

positive

negative

___/___/______

__ __ : __ __

am

pm

Microscopy
Thick Smear

___/___/______

__ __ : __ __

am

pm

positive

negative

___/___/______

__ __ : __ __

am

pm

RDT (Binax Now)

___/___/______

__ __ : __ __

am

pm

positive

negative

___/___/______

__ __ : __ __

am

pm

PCR

___/___/______

__ __ : __ __

am

pm

positive

negative

___/___/______

__ __ : __ __

am

pm

Antibody testing

___/___/______

__ __ : __ __

am

pm

positive

negative

___/___/______

__ __ : __ __

am

pm


Species (check all that apply)

Vivax Falciparum Malariae Ovale Not Determined Other species (specify) __________________

Parasitemia (%): _______________________


Public reporting burden of this collection of information is estimated to average 5 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 (0920-1026).



Was a travel history taken for this patient? Yes No Unknown

Is the patient a US resident? Yes No Unknown

Has the patient traveled or lived outside the U.S. since December 2013? Yes No If yes, specify:

Country:

1. ________________

2. _________________

3. ________________

Date ARRIVED IN the country (mm/dd/yyyy):

Date DEPARTED the country (mm/dd/yyyy):

____/ ____/ ______

____/ ____/ ______

____/ ____/ ______

____/ ____/ ______

____/ ____/ ______

____/ ____/ ______





Clinical Cerebral malaria ARDS None Was illness fatal: Yes No Unknown

Complications: Renal failure Severe anemia(Hb<7) Other : ____________ If yes, date of death : _____/____/_______



Therapy for this attack (check all that apply)

Was this medication given?

Date and time medication given
mm/dd/yyyy hh:mm

Artemether/lumefantrine (Coartem)

Yes Unknown

No

___/___/______

__ __ : __ __

am

pm

Artesunate

Yes Unknown

No

___/___/______

__ __ : __ __

am

pm

Atovaquone-Proguanil (Malarone)

Yes Unknown

No

___/___/______

__ __ : __ __

am

pm

Chloroquine

Yes Unknown

No

___/___/______

__ __ : __ __

am

pm

Clindamycin

Yes Unknown

No

___/___/______

__ __ : __ __

am

pm

Doxycycline

Yes Unknown

No

___/___/______

__ __ : __ __

am

pm

Mefloquine

Yes Unknown

No

___/___/______

__ __ : __ __

am

pm

Quinidine

Yes Unknown

No

___/___/______

__ __ : __ __

am

pm

Quinine

Yes Unknown

No

___/___/______

__ __ : __ __

am

pm

Other (specify): _____________________

Yes Unknown

No

___/___/______

__ __ : __ __

am

pm


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleMALARIA CASE SURVEILLANCE REPORT
AuthorCGH DPDM
File Modified0000-00-00
File Created2021-01-27

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