Contact Specimen Collection Form

Ministry of Health, Federal Democratic Republic of Ethiopia

Official Use Only: Information for index AFP case:

Epid Number: ETH/ _______ ________ _______ _______ Received: ____/____/____
Region Zone Year Onset Case Number

Contact specimens should be collected if:

1. Not able to collect 2 stool specimens from the AFP case within 14 days after onset of paralysis including
those who have died before 2 stool specimens can be collected.
2. In an emerging Region (specifically Somali, Afar, or Gambella) or a zone with non-polio AFP detection rate
under 2.0 cases per 100,000
3. All AFP cases whose stool sample was labelled as “BAD” by laboratory
4. Requested to be done by Central WHO Office.

COMPULSORY NOTIFICATION (PLEASE COMPLETE ALL INFORMATION IN FULL)

Information of INDEX AFP Case (to link the contacts):
Address: Region: Zone: Woreda:
Kebele Village/Gote:
Specific location/ identifier
Name(s) of AFP Case Father’s name: Grandfather’s name

Information of Contact:
Contact Number (circle one) 1 2 3

Address: Region: Zone: Woreda:

Kebele Village/Gote:
Specific location/ identifier
Name(s) of contact Father’s name Grandfather’s name

Mother’s name full:

Date of birth ___/___/___ If DOB unknown: Age years: _______Months: ______ Sex:  M=Male F=Female

Did contact receive OPV before case got paralyzed?  Y=Yes N=No U=Unknown
If Yes: Number of OPV doses: ____EPI doses ____ NIDs or SNIDs doses
Date of last OPV dose ___/___/___
STOOL SPECIMEN COLLECTION:

Date stool collected ____/_____/________ Date stool sent from field to national level ____/____/____
TO Be Completed by Laboratory:
STOOL SPECIMEN RESULTS: Primary isolation result
Date stool specimen Condition of stool Date result sent by Date result received by national P1 P2 P3 NP-Ent
received by national 1=Adequate 2=Not adequate National Lab to National level Level:_____/_____/____
Lab: ____/____/_____ ____/____/_____

1= Yes 2= No 1=Yes 2=No

W1 W2 W3 V1 V2 V3 NP- Net
Date isolate sent from Date differentiation result Date differentiation result
National Lab to Regional sent by Regional Lab: received by National Level
Lab. ___/___/___ ____/____/____ ____/____/___ 1= Yes 2= No 1= Yes 2=No 1=Yes
2=No

Instructions:
1.Collect only 1 stool specimen from each contact preferably while collecting the stools for the AFP case
2.Prioritize contacts under 5 years living in the same house as the AFP case.
3.If there are less than 3 contacts in the house, choose the closest playmates or neighbors of the AFP case
4.Fill a contact specimen collection form for each contact.
5.Use the same specimen collection procedures and reverse cold chain as for the AFP case specimen collection.
6.Use one vaccine carrier for all contact specimens and a separate vaccine carrier for the case specimens. If this is not
possible, use plastic zip lock bag for putting the contact samples separate from the AFP sample and take with one
vaccine carrier.

Signature of the Health Worker Collecting the Contact Samples: ____________________