'MMEDIATE NOTIFICATION OF ACUTE FLACCID PARALYSIS (AFP) CASE Poe EIL OE Feet ___ O%33 ~ 93.960 44- Thereby notify the occurrence of a case of Acute Flaccid Paralysis Und etwnso%d District: Telephon Wy Pationt’s Name oe¥,# Complete Address: House Ne. Ak Z Street Mohalla ie, Village: ue Ure se Se a} uy, Union CouncitWard: 54/5 Fameresame cata Uh dwn "Pops f crand raters Name pees ALM Yfrofe or Tehsil / Taluka/Town syst (3 a G District ies fou! s Telephone <9} Date of Birth Day Month ‘Year Age in Months: ~ Male Female tht o af Je Sure se 7 2 str = —_= TT v Date of Onset of Day Date of Case | Day | Month | Year Weakness/Paralysis ” o we | Je 1 ar 03, So | 69 [Roz) Site of Paralysis: Cue Agub ‘The case referred to: Notited By: 9c wht sian i Designations af Addeess % [KTR £ Ms Phone Nosy ‘Thank you for notifying this AEP case. Pee swift ‘lease mention relevant case history atthe back of this form Scanned with CamScanner aeCase Investigation Form for Acute Flaccid Paraly: (AFP) Case Urgent Case 7] Notifying district ‘ Data cof ottication | Date of investigation | NOC EPID NUMBER we nays | Date of Notification igation | Ageney! Town pak sDi37 2p ieylOB/o6/at_ |30[o9|ava1 [Bi] 10 Poa! Misporshhos TaieisNane: CU) aty t ‘Age athe tine of onset of para sivweainess Gaimonihsy 1 wapeilhs | S* Grand Fathers Name Fathers Occupation haut NY Fist Language Urdu Parabi Sarak (indi) Balochi” Bra / Pashto /Mindko Patan Shina “Potpper Other; please mention Ahan, jn oii st Adress: House No, ———— Street Mohalla Village Da. Union Counc Identification | Tehsil/Taluka/ Town. £ J Const ube: - ox — ‘Does the child belong to migrant mobile population group: Yes 2 No (~ yes emir appropriate option (et oe type of mantle population gp) |. Bric-Kiln workers 2, Agu Migrants 3.Indstiaconsncton workebores 4 ntl dp peoen(IDPs) Nanas ange sen nate camer ep pind flava) & Aan Natl Returce 1. (Seson Emi Mrs Re Hh Rk Gos) Notified by: Name & Designation: SA, (1G poe Fy — Tr seat ingens one prope opon)” T Aang Sunellnce Ste 2 Zero Reporng is (wich outeation | THPE reporting cea cli eae oe APRONS oy Public/Armed Forces Private/Informal health care provider Comrkunity based ‘AFP case Admitted in Hospital Health facility: Yes C) No WW/¥es, Date of admission Ifthe patient died, date of death Health care provi ‘onset of paralysis till the notification) Pa ar ell | eae Uitcticed euch en) visited (ert Ufa ane + Shtha_De Surat b Meant it, Speci ay pr weakness ies o ther nerlons ody {peat ormainion 7 Te Verify: Is wealnessparlsis aut (sudden and api posession?” Yay)” No Is weakness paralysis acid? (i. opp9) No Tirveakness(paralysis isnot acute & flaccid, stop investigation Specify diagnosis (if known) for excluded cases only ‘Was there fever atthe onset of weaknessiparalysis? & No/ Unknown ! signs [sth weknessparayis amet? No ME [Haw many days it ook fom the time of weakness paralysis onset ofall installation of weakness paralysis? Symptoms dsys_OUnknown Rightly eg) [Right tam] Tet Facial speily Breathing msces | NER | Fatal | ocutar muscles ‘Where she weakness paralysis in arms? Proximal _| Disa Nether Whereis the weakness paralysis in eg? Proximal | Disa Neither Scanned with CamScannerUpper limb Lower limb [Neurological Examination ological Examinatl ‘Arm (Proximal) Forearm (Distal) “Thigh Proximal) Leg( Distal) Right Left Right Left Right Left Right Left ekerteneen) N Aa Beye] N Sago Reet a a paereeuaeecees, | Sg IG Shs Is Is As Is As [Proximal Reflexes pwmwenn womens [BRET [ICTS nee nee |omns rns memes renee ta a | i rage —_aawe ea aan nwa [ensation muon pa dian Riot Natu ‘aia clivear [ale Hi haa | [Plantar rene mete anes soy MO Yeates History of Intramuscular Injection 24 hours before the onset of paralysis'weakness Yes No Injection [HEesi mention he sit of nection in below we WD Left | History yes, 7 Fa TT TTT RENT NT eT ret Routine OPV doses verified by EPI.card_Yes O No Tfyes, write Card Number,_—— ‘Name of the Centte__———— rer Bitional OPV doves received during Immunization Campaigners (pwes] Doses S| Unknown recall) - ‘Number of OPV doses received 5 AV So [Boxes ag rom he recent most. _[4[Ve)/8o_S) (Vi No 6) Yes/No + Immunization | oe Fret valid OFV Joss recess doses ast F weeks apart Tncluding both Routine and Supplemental: History | 5 the child eligible for IPV. Yes®/Not] IPV doses received? ‘YerWNoL|if yes: date received: Hin PV dose received in RI_EY-] [No.of IPV dose reveived in HA ot ed ot mmnized of mised se OPV Goss Gain HEC mention the Fey eason (please encircle one ofthe reasons below) reson Peatvery issue” 2. Refusal 3. Area of esidenceInacessi 4. Other, please specify: —_ Date of last OPV dose received le for vaccination teams du to insecurity claw ma arabs DAV. DEr| Aironet of ann S19 Date sent to Lab 2/0 / 22% Date of collection: ‘Stool jirst stool specimen: Specimen es Pe 2 a Contection & | second stoolspesimen: | Dateofoletion Dare wentwotab 2-10) PT Dupeich Seabee fer AFP eases patency wan 68 OF veo No O7ifyes, number of re ncoparalysis onset es coker AE en ey Fa se Found (oRTanter ses ea) cases in the Locality spa an wih Cifice Revives om Jen, 2020. Scanned with CamScannerLABORATORY REQUEST FORM FOR IDENTIFICATION OF POLIOVIRUS {To accompany stool specimen being sent to laboratory for AFP investigation) = Noel routine OFF doses [Consider AFP cave with folowing t labeled ax wrgent: ] | Ungont Care 11 Clinical Poly? - No of SI OPV doses : Repl pe Lisa een High Risk Area/Population? vi > No of IV cases + Age 13-38 months CT vi + Zero done for OP ‘Country: Pakistan Patient's Name CTA Father's Name: Wy Hammon YOus ae WFcontact specimen, reason for selecting the child as a contact/sibling/housemate/school TPID No, PARI 73121 1044 sx (0) imate/playmate/commanity Adress: House No Stree Mohalla Village: ALR Tach ACF Aran TARY Union CounciWard/Area: Dou (WeGar , TehsilCity Town/T De FenBMy Di Dtie Puekepons Da jon ear _ Date of Bint of Patient = oe = Pace of Patienvcontact atthe time of onset of paralysis Gia months) 71 Mowh- Date of onset of paralysis / weakness 0G Date of last OPV dose received (before onset of paralysis) 03 Date of last OPV dose received (after onset of paralysis) Date of first stool specimen collection Date first stool specimen sent to laboratory Date of second stool specimen collection Date second stool specimen sent to laboratory Place of stool specimen collection: Home’ Hospital $2 Afeme Provisional Diagnosis ACen hv DHeah Hemplrgn. "AFP case eligible for contact specimens collection asoring coma er %e Ne ‘Please fill the following section if contact specimens have been collected) ‘Reason(s) for collecting contact specimens: Check (\) the appropriate box(es) ) Inadequate specimens from AFP case 'b) Urgent case from hard to reach area € ©) Urgent case from insecure area € <) Case from area of special concem € €) Late notification 1) Index case died before sample could be collected 2) Index ease left the area before samples could be collected hi) Index case is constipated ano peso om SR fab — arn Designation Sr Signtues LOE a awe) (0) > 21 Contact = 0033 19536, (FOR USE BY LAMORATORY) Date received at laboratory: Day___Month_Year_Case Lab, No.__ Condition of specimen: cB == Good ~ Poor] Tanuary 2021 Tote dne cine wt picid nlf eer ‘ean scopy of hs formforrcof Datst Hasih Of od mdr to WORK Larry fr Pls Erato IH. Scanned with CamScannerLABORATORY REQUEST FORM eh Samples FOR IDENTIFICATION OF POLIOVIRUS Caving mrpe He {To accompany stool specimen being sent to laboratory for AFP investigation) ~ No of routine OPV doses. [Consider AEP case with following to labelled Un rm: | [- Unsent Case: (he Clinically Polio)? Yi > High Risk Area/Population? y OPV Doses “1? ves) |- No of SIA OP doses w" Fever before onset + No of IPY doses Rapid progression of weakness 2 Age 1238 monn + Zrodone for OPV ‘Country: Pakistan EPID No. PAK IG 37 7 704 Patients Name: ABS) VALI ser (@)_ uher’s Name: yy HmnmMd_K/ION contact specimen, reason for selecting the chil as a contact sibling /homsemate schoolmate playmalclcommanity ‘Adress: House Ne: Sirec/ Mohalla Vilage: AZ Gputim 2 Rito 7 FTE Union Councit Wardarea DY SUTE oS Tehsil/City/Town Taluka: —_C Ahy zener District PUK. Day Month Yar Date of Birth of Patient g¢ of Patient/contact atthe time of onset of paralysis (in months) 2 Plonth Date of onset of paralysis / weakness Date of last OPV dose received (before onset of paralysis) — Date of last OPV dose reesived (after onset of paralysis) — Date of first stool specimen collection Ob 10 20% Date first stool specimen sent to laboratory og Oo 20>4 ate of second stool specimen collection — — = Date second stool specimen sent to laboratory = = = Place of stool specimen collection: Home/ Hospital S1_[-beme S2 Provisional Diagnosis ‘AFP case eligible for contact specimens collection (according to county ertera®) Yer Ne ‘(Please fill the following section if contact specimens have been collected) ‘Reason(9) for collecting contact specimens: Check (X) the appropriate box(es) ®: Inadequate specimens from AFP case ») ) Urgent case from hard to reach area € ‘) Urgent case from insecure area € 4) Case from area of special concer € Late nifieation 1 ndex case died before sample could be collected index cave lef the arc before samples could be calecied / 1h) Index case is constipated Name of person completingform, DW AIS DAC — CATE | designation LSE TAP 3 Signatures:_p__>" pate {] 12 | 2241 Contact #_OS0033 | (FOR USE BY LABORATORY ) Date receifed at laboratory: Day ‘Month Year Case Lab. No, [5-2 —- Good ——- Poor] Condition of specimen: [5 Name of person receiving specimen(s) Tmadeguae AFP can med Bp of tt ofa ope Tanoary 2021 {Tobe ine caramel ear an po ff cdo Dt Meath Ofelia 1 WORK Lary Ps rabatn NIM lamabad Scanned with CamScannerLABORATORY REQUEST FORM FOR IDENTH ICATION OF POLIOVIRUS Comtade Supe y: (To accompany stool specimen being sent to laboratory for AFP investigation) No af routine OPV doses (Consider AFP case with following to labelled as urgent: || Urgent Cave (ie Clinalh Polo)? YN |- No of SLA OPV doses : Pav sctbercal ere }- High Risk Area/Population? YN No af PV doves 1 Repl progression OPH Doves 1? yn} + Zens dove for OPY ‘Country: Pakistan EPID No. PAK/

‘Date of second stool specimen collection = = _ Date second stool specimen sent 0 laboratory = = _ Place of stool specimen collection: Honig! Hospital st Heme S2 Provisional Diagnosis "AFP case cliible for contact specimens callction scoring oun een) T= Ne (Please fil the following section if contact specimens have been collected) ‘Reason(s) for collecting contact specimens: Check (X) the appropriate box(es) ,) Inadequate specimens from AFP case 'b) Urgent case from hard wo each area € ©) Urgent case from insecure area € &) Case from area of special concer € ) Late notification ‘Index case died before sample could be collected B) Index case eft the area before samples could be colleqed > case is constipated Sa Nato pen oR 2 TET ITE ion DECAPR Signatures: Date -f_[ [0/20>7 Contact # O3CO33 S736 (FOR USE BY LABORATORY) Date receivedfat laboratory: Day Month Year tase Lab, No, == Gownd == Poor Name of person receiving specimen(s) = Tana ace fl es co oo pe January 2021 (Tote din in coeoaton nh prince fbr eerie ‘sain py of som or rdf Das eth Of amend erg ts BHO RK Lory fr Pb Brats Scanned with CamScanner- ae rok wENTIFIEATION OFFaLiovinus — COMMER {To accompany stool specimen being set to laboratory fr AFP investigation) [> No of routine OPY doves (Consider AFP case with following = Urgent Case: the Clinically Polio)? ¥ |- No af St4 OPF doves Fever before onet |: High Risk Area/Population? v + Rapid progresion of weakness > oe ~ No of PY doses 1 lapid progresion | opr Doves <3 vel + Zar dove for OPY | Country: Pakistan EPID No. PAK XD 13/ 0p 004 Patient's Name: 7 FAR GONE Sex _(@) Father'sName: S72 Aa contact specimen, reason for selecting the child as a contact /sibling/housemate’schoolmate/playmatelcommunity ‘Adress: House No Stree Mohalla] Vilage: ATIR GRehm AC Atom (NPR Union CouncivWardarea CEL CIR. ‘Tehsil/City/Town Taluka: TARY HIBATY District: PRP HR OS, Date of Birth of Patient Be Sen vee \ge of Patientcontact at the time of onset of paralysis (in months) Ze ACH Date of onset of paralysis / weakness : 5 Date of last OPV dose received (before onset of paralysis) ~ = : Date of last OPV dose received (after onset of paralysis) 5 = Date of first stool specimen collection os Te © Date first stool specimen sent to laboratory OF 10 RO2) ate of second stool specimen collection = = = Date second stool specimen sent to laboratory = = = Place of stool specimen collection: Home! Hospi Provisional Diagnosis [AFP case eligible for contact specimens collection (according wo country etera®) Yeu Ne (Please fill the following section if contact specimens have been collected) ‘Reason(s) for collecting. contact specimens: Check (\) the appropriate box(es) ) Inadequate specimens from AFP case 'b) Urgent case from hard to reach area € ‘€) Urgent case from insecure area € 4) Case from area of special concer € ©) Late ou 1 Inder case died before sample ould be calcd g) Index ase lft the area before samples could be calleicd tion 1h) Index case is constipated ‘Name of person completing form: 3Du Ca Designation__D>S © J9XC _ Contact #_ 306033 GF 3C Signatures: (FOR USE BY LAB Date received allsboratory: Day __Month_Ye Good == Poor) [5-2 == Good [Name of person receiving specimen(s at labora: Condition of specimen: [S= Taal AF as td tn Ba of da of oe opr January 2001 (Tae dine consntaon wth prob fo a ‘eta 9 of a orm a cde ist Hes Ofc wd el erga ty WHORR Uabraty or a Breton NI ama Scanned with CamScanner