NIPPON EXPRESS CO.

, LTD

Investigation Form for Malaria

Basic Information:

Name: _____________________________________________________

Job Description ________________________ Section ____________________________

Room No: ____________________________

Early Diagnosis and Treatment:

Symptoms first noted: Date _______ Time _______ Location ________

Fever ___ Chills ___ Headache ___ Diarrhea ___ Others ____

Consultation: Date _________ Time ______ Location ______________

Treated / Medical Consultation at __________________________________________

Diagnosis: Date _____________ Time _______

Location ________________________

Confirmation: Microscopic slide ____ ICT ____ QBC ____

Other_____ None ____

Treatment Date ______________ Time __________

Medication given ___________________________________________________

Awareness:

Indicate when person received information / training on malaria transmission, prevention, and
treatment?

Initial Training _______________ Refresher Training ________________

If not, note reason(s)

___________________________________________________________________________
 NIPPON EXPRESS CO., LTD

Investigation Form for Malaria

Bite Prevention:

Suspected time and location where bite occurred._____________________________________

What bite prevention measures were used? (Indicate response by x)

Use of repellent _____ Use of Permethrin on clothes _____

Wears long sleeves / pants _____ Use of bed net _____

If not, note reason(s).

Vector control measures implemented at this location?

Are these vector control measures implemented in accordance with the Malaria Control Plan?

Yes _____ No _____

Chemoprophylaxis:

Was prophylaxis taken according to regimen recommended by Medical Advisor?

Yes _____ No _____

Date person began taking prophylaxis __________

Type of prophylaxis _____________________________

Frequency _________________

If not, note reason(s)

Other Comments:

Form Completed By: __________________________________________________

 NIPPON EXPRESS CO., LTD

Investigation Form for Malaria

Date Form Completed: _______________________

Note!!!The results of the investigation are confidential.