[COUNTRY] : Laboratory Investigation Form FOR-Q05-003-01

1. Patient Information .
1.1Last
5.6.Case/Specimen
Date of Onset of Illness. .
Status 7. Outcome ..
Name ∟∟∟∟∟∟∟∟∟∟∟∟∟∟ ∟ ∟m m ∟y ∟y
d d y ∟
y
Hospitalized?  Y  N  DK
1.2
First Died?  Y  N  DK
8. Signs and Symptoms . .
Name ∟∟∟∟∟∟∟∟∟∟∟∟∟∟  Fever  Temp: _________________  Onset: _dd_ _mm_ _yy_
1.3
Patient ID
d d m m y y y y  Rash  Location: ______________  Onset: _dd_ _mm_ _yy_
∟∟∟∟∟∟∟∟∟∟∟∟∟∟  Pain  Location ______________________________________
1.4
Gender  M  F Age∟∟∟ years 1.5  Hemorrhagic symptoms  describe _______________________
 Altered mental state  Convulsions  Jaundice
months  Chills  Coryza  Neck stiffness
 Circulatory collapse  Cough  Lymphadenopathy
2.Date
1.6 Referring
of BirthDoctor ∟∟ ∟∟ ∟∟∟∟ .  Conjunctivitis  Diarrhoea, Acute
 Diarrhoea, Chronic
 Kernig’s sign
 Paralysis
1.7
Street Chronic Conditions
2.1
Name:_# # - _______________________________
____________________________________  Autoimmune disease  Failure to thrive  Respiratory, Upper
 Connective tissue disorder  Genital discharge  Respiratory, Lower
2.2
Reporting Address:__________________________  Lymphoproliferative disor  Genital lesions  Vomiting
 Transplant recipient/donor  Hepatomegaly  Weakness of limbs
____________________________________________________  Immunocompromised  HIV +ve  Weight loss
2.3
 Other  specify
3.Tel: _________________
Provisional Fax:
Diagnosis, Additional Notes1 .
_________________ 9. Syndromic Classification .
 AFP  Fever & Rash
 Gastroenteritis  Fever & Respiratory or
 Fever & Hemorrhagic Acute Respiratory Infection
 Fever (undifferentiated)  Fever & Neurologic
1
information on risk factors, travel history, lab findings, etc.
10. Immunization History . EPI No: __________
4. Food/Animal/Environment Sample Details (if relevant)
BCG:  Y  N dd_ _mm_ _yy_ MR: Y N dd_ _mm_ _yy_
4.1
Specimen ID_________________________________ DPT:  Y  N dd_ _mm_ _yy_ Polio: Y N dd_ _mm_ _yy_
4.2
Name of food/env sample_______________________ HBV:  Y  N dd_ _mm_ _yy_ YF: Y N dd_ _mm_ _yy
4.3
Where specimen(s) collected____________________ MMR:  Y  N dd_ _mm_ _yy_ Other‡: Y N dd_ _mm_ _yy_
4.4
 Outbreak  Traceback  Survey  ‡
specify ______________________________________________________
Other.
*Serum; EDTA blood; Blood smear; Sputum; CSF; Swab; Urine; Stool; Tissue; Plasma (PPT);
esUbaLlanoit UsePhysician / EHO

Food;Water;Animal;Environment; if other specify

Specimen 1 Specimen 2 Specimen 3
11
Type of Specimen
12
Date Specimen Collected

13
Lab Test(s) Requested

14
Date Received at Nat Lab
15
Nat Lab Specimen ID
Laboratory Use

16
Test(s) Performed

17
Date(s) Tested
18
Laboratory diagnosis

19
Date Referred to CARPHA
20
Name of Testing Lab

21
Approved by (Testing. Lab): ______________________________ Date: __________________
22
CARPHA USE: Specimen ID (1)_____________________ (2) __________________ (3) ________________