Version 2022

Epidemic-prone Disease Case Report Form

Case Surveillance Cholera (ICD 11 Code: A00)
NCR
Region of DRU: ______________ Province of DRU: _______________ BARANGAY
METRO MANILA Barangay of DRU__________ X Site : Sentinel Site Non– Sentinel Site
Name of DRU: ABC HOSPITAL
________________________________________________________________ Type: RHU/CHO Gov’t Hospital Private Hospital Clinic
CHRISTINE P. AÑO Contact Number of Interviewer: _____________
Name of Interviewer: ________________________ 09653211670 Private Laboratory Public Laboratory Seaport/ Airport Other: __________

Indige- Con- Place of Date onset of

Complete Current Ad- Complete Permanent Date of FIRST Admitted? Date Admitted/
Patient No. Patient’s Full Name Age Sex Date of Birth nous sulted Consultation illness (FIRST
dress Address People ? consultation Seen/Consulted
symptoms)

SANTOS, CLARA B. 6YR F ABC Y

012345 12 22 14
___/___/___
12345 STA. CRUZ STREET,
BARANGAY X, PACO MANILA
12345 STA. CRUZ STREET,
BARANGAY X, PACO MANILA N Y 03 12 21
___/___/___ HOSPITAL 03 12 21
___/___/___ 03 07 21
___/___/___

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Age: Indicate
D - days Specify House #
Specify House # Please
Response M - months Street / Purok/Subdivision,
Indicate Last name, First Street / Purok/Subdivision, specify Y - Yes Name of Y - Yes
Codes / Yr. - years mm/dd/yyyy Barangay, Municipality/ mm/dd/yyyy mm/dd/yyyy mm/dd/yyyy
name, Middle name Barangay, Municipality/ City, what N- No Facility N- No
Instructions Sex: City,
Province, Region tribe
F - Female Province, Region
M - Male

Case Definition:
 Suspected case: In an area where cholera outbreak has not been declared: Any patient aged 2 years and above  Probable: A suspected case that is cholera RDT positive.
presenting with acute watery diarrhea and severe dehydration or dying from acute watery diarrhea.  Confirmed case: A suspected case that is laboratory-confirmed through isolation of vibrio
cholera 01 or 0139 from stools in any patient with diarrhea.
In an area where cholera outbreak is declared: Any person presenting with or dying from acute watery diarrhea

Deliberately providing false or misleading, personal information on the part of the patient, or the next of kin in case of patient’s incapacity, may constitute non-cooperation punishable under the Republic Act. No. 11332
 Version 2022

Epidemic-prone Disease Case Report Form

Case Surveillance Cholera (ICD 11 Code: A00)

Date of
Main source of Laboratory Laboratory Case
Patient No. Patient’s Full Name Age Sex Date of Birth Specimen Organism Outcome Date of Death
drinking water Test Result Classification
Collection

012345 SANTOS, CLARA B. STOOL Vibrio A

6YR F 12 22 14 NAWASA 03 13 21 CULTURE P cholerae 01 C
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Culture
PCR- Polymerase Chain
Age: Indicate Reaction P - Positive
D - days Vibrio Cholera 01
Well Sero- Serotyping/ N - Negative
Response M - months Vibrio Cholera 0139 S—Suspect A - Alive
Indicate Last name, First name, Middle Spring serogrouping PR— Pending
Codes / Yr. - years mm/dd/yyyy mm/dd/yyyy ND– Not done P—Probable D - Died mm/dd/yyyy
name Local Water System RDT- Rapid Diagnostic Result
Instructions Sex: NA– Not applicable C– Confirmed
F - Female Commercial Water Test ND - Not done
U– Unknown
M - Male ND - Not done
U– Unknown

Case Definition:
 Suspected case: In an area where cholera outbreak has not been declared: Any patient aged 2 years and above  Probable: A suspected case that is cholera RDT positive.
presenting with acute watery diarrhea and severe dehydration or dying from acute watery diarrhea.  Confirmed case: A suspected case that is laboratory-confirmed through isolation of vibrio
In an area where cholera outbreak is declared: Any person presenting with or dying from acute watery diarrhea cholera 01 or 0139 from stools in any patient with diarrhea.

Deliberately providing false or misleading, personal information on the part of the patient, or the next of kin in case of patient’s incapacity, may constitute non-cooperation punishable under the Republic Act. No. 11332