ID: □□□□□□ □□□□ MEASLES CASE REPORTING FORM

I.CASE IDENTIFICATION/ DEMOGRAPHIC DETAILS

Patient name Father’s name Family card number Ethinicity
National
 Forcibly-Displaced
Myanmar National
 Other
Occupation Phone: Male Female Pregnant
School name, if applicable:
Date of examination: (dd/mm/yy) ___/_______/___________
If date of birth unavailable please indicate age in month or years: Date of birth
Age: (Years) (Months) ____ /____/________
Mahji name Mahji phone Mosque name Imam name

Address Information
For Forcibly-Displaced Myanmar case Zone Block House number

For National case Village Union / Ward Upazila District

II. VITAL SIGNS ON INITIAL EXAMINATION:

Date of examination (dd/mm/yy)
Temperature (°C)
III. BACKGROUND INFORMATION:
Measles / MR / MMR containing
vaccine doses
Number of total doses
 Zero  1  2  Unknown
Date of last vaccination (dd/mm/yy)
______ /__________ /___________
 Vaccination card  Self-reported
___/_______/___________
Contact with known case of measles/similar illness in 7-18 preceding days
 Yes  No  Unknown
If yes, details ______________
Number of persons living in the household? _____
Other people with similar illness in the family?  Yes  No
If yes, details_________________

Vitamin A received? Attended health care facility in last 18 days:  Yes  No

 Yes  No  Unknown If Yes, date: ____ /____ /______ Location:________________

Period of communicability: usually 5 days prior to rash onset until 4 days after the onset of
the rash.
IV. CLINICAL DETAILS
Symptoms Complications:
 Fever, Date onset fever: ______ /_____/________  Diarrhea
 Rash, Date onset of rash: ______ /_____/________  Pneumonia
 Cough  Encephalitis
 Coryza (runny nose)  Meningitis
 Conjunctivitis (red, watery eyes)  Serious eye disorders
 Koplik spots (tiny white spots inside the mouth)  Ear infection
 Other, specify ____________  Febrile seizures
 Other, specify ____________

Version: 19 January 2018

ID: □□□□□□ □□□□
Was patient admitted?
 Yes  No Date of admission: (dd/mm/yy) ______ /________/___________

VI. SPECIMEN COLLECTION

Specimen collection done?  Yes  No
Date of collection: (dd/mm/yy):
_____/______/________
Type of sample:  Blood
 Nasalpharygeanl swab
 Urine
Lab results  Positive  Undetermined
 Negative  Not processed
Date of results: (dd/mm/yy):
____/______/________

VII. DISCHARGE DETAILS

Date of Discharge
____ /________/_________
Outcome at discharge
 Recovered
 Death ……………………………………..(Fill mortality line list)
 Referred
 Other, specify ____________

Version: 19 January 2018