VHF Case Investigation (Short Form) - English

[NAME OF COUNTRY]

VIRAL HEMORRHAGIC FEVER

CASE INVESTIGATION FORM (SHORT VERSION)

Form Approved

OMB Control No. 0920-xxxx

Expiration Date xx/xx/xxxx

Outbreak

Case ID:

Date of Case Report: ____/____/_____ (D, M, Yr)

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. 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 Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX.

Section 1. Patient Information

Patient’s Surname: ______________________ Other Names:__________________________

Age: ______ Years Months Gender: Male Female

Phone Number of Patient/Family Member: __________________________

Status of Patient at Time of This Case Report: Alive Dead If dead, Date of Death: ___/___/___ (D, M, Yr)

Permanent Residence:

Head of Household :____________________ Country: ___________________ District: ____________________ Sub-County: ____________________ Parish: ____________________ Village/Town: _____________________

Occupation:

Healthcare worker; position: ____________________ healthcare facility: ______________________

Other; please specify occupation: ________________________

Location Where Patient Became Ill: Country:________________________

District: ________________________ Sub-County: ____________________ Village/Town: _________________

Section 2. Clinical Signs and Symptoms

Date of Initial Symptom Onset: ____/____/______ (D, M, Yr)

Please mark an answer for ALL symptoms indicating if they occurred during this illness:

Fever Yes No Unk

Vomiting/nausea Yes No Unk

Diarrhea Yes No Unk

Intense fatigue/weakness Yes No Unk

Anorexia/loss of appetite Yes No Unk

Abdominal pain Yes No Unk

Chest pain Yes No Unk

Muscle pain Yes No Unk

Joint pain Yes No Unk

Headache Yes No Unk

Cough Yes No Unk

Difficulty breathing Yes No Unk

Difficulty swallowing Yes No Unk

Sore Throat Yes No Unk Conjunctivitis (red eyes) Yes No Unk

Skin rash Yes No Unk

Hiccups Yes No Unk

Unexplained bleeding Yes No Unk

If yes, please specify: ________________________

Other non-hemorrhagic symptoms: Yes No Unk

If yes, please specify: ________________________

Section 3. Hospitalization Information

At the time of this case report, is the patient hospitalized or being admitted to the hospital? Yes No

If yes, Date of Hospital Admission: ____/____/_____ (D, M, Yr)

Health Facility Name: __________________ District: ________________ Village/Town: ______________

Is the patient in an ETU (isolation) or currently being placed there? Yes No

If yes, date of isolation/admission to the ETU: ____/____/_____ (D, M, Yr)

Was the patient hospitalized or did he/she visit a health clinic previously for this illness? Yes No Unk

If yes, Dates of Hospitalization: ___/___/____ - ___/___/____(D, M, Yr)

Health Facility Name: _________________ District: ________________ Village/Town: _______________

Section 4. Epidemiological Risk Factors and Exposures

In the past ONE(1) MONTH prior to symptom onset:

1. Did the patient have contact with a known case or any sick person before becoming ill? Yes No Unk

If yes, please complete one line of information for each sick source case:

Name of Source Case	Relation to Patient	Date of Last Contact (D, M, Y)	District	Village/Town	Was the person dead or alive ?
		___/___/___			Alive Dead, date of death: ___/___/___ (D, M, Yr)
		___/___/___			Alive Dead, date of death: ___/___/___ (D, M, Yr)

2. Did the patient attend a funeral in the one month before becoming ill? Yes No Unk

If yes, Name of Deceased Person: _____________________ Relation to patient: _______________________

Date of Funeral: (D, M, Yr): ___/___/____ District: ________________ Village/Town: ________________

Did the patient participate (carry or touch the body)? Yes No

3. Did the patient travel outside their home or village/town before becoming ill? Yes No Unk

If yes, District: _______________ Village/Town: _______________ Date(s): ___/___/___ - ___/___/___ (D, M, Yr)

Section 5. Clinical Specimens and Laboratory Testing

Has this patient had a sample submitted previously? Yes No

Submitting Health Facility: _________________________ Submitter’s Name: ___________________________

Submitter’s Phone Number: ________________________ Submitter’s Email: ____________________________

Sample 1: Sample 2:

Sample Collection Date: ____/____/______ (D, M, Yr) Sample Collection Date: ____/____/______ (D, M, Yr)

Sample Type: Sample Type:

Whole Blood Whole Blood

Post-mortem heart blood Post-mortem heart blood

Skin biopsy Skin biopsy

Saliva swab Saliva swab

Other specimen type, specify: _____________ Other specimen type, specify: __________

Section 6. Case Report Form Completed by:

Name: __________________________ Phone: ______________________ E-mail: ________________________

Section 7. Patient Outcome Information

Please fill out this section at the time of patient recovery & discharge from the hospital OR at the time of patient death.

Date Outcome Information Completed: ____/____/_____ (D, M, Yr)

Final Status of the Patient: Alive/Recovered Dead

If the patient has recovered and been discharged from the hospital:

Name of hospital discharged from: ___________________ District: ___________________

If the patient was isolated in an ETU, Date of discharge from isolation: ____/____/____ (D, M, Yr)

Date of discharge from the hospital: ____/____/______ (D, M, Yr)

If the patient is dead:

Date of Death: ____/____/_____ (D, M, Yr)

Place of Death: Community Hospital: ___________________ District: ___________________

Date of Funeral/Burial: ___/___/___ (D, M, Yr) Funeral conducted by: Family/community Outbreak burial team

Place of Funeral: District: __________________ Sub-county: __________________ Village: ________________