Pidsr Mop 3rd Edition WNDR CRF Cif

Philippine Integrated Disease Republic Act 3573 (Law of Reporting of Communicable Surveillance and
Response Diseases), requires all individuals and health facilities to

report notifiable diseases to local and national public health authorities.
Weekly Notifiable Disease Report

Summary Page
Name of Disease Reporting Unit: PRESIDENT RAMON MEMORIAL HOSPITAL
Type of facility:  Gov’t Hospital  Private Hospital  Rural Health Unit  Clinic
 City Health Office  Gov’t Laboratory  Private Laboratory  Seaport/Airport
Address: PUROK 4, PALANGINAN, IBA, ZAMBALES Tel. No.______________
This report was prepared by: DALISAY SAHAGUN, RN, MAN Date: 10 / 04 / 2022
(Signature over printed name)
This report was submitted to Date: 10 / 04 / 2022
(Name of RHU/CHO/PHO/CHD): PROVINCIAL HEALTH OFFICE
Date: ____/____/____
This report was approved by: NOEL BUENO, MD
List of Notifiable Diseases/Syndromes
Indicate the number of case/s in the corresponding line for case/s of disease/ syndrome
seen and “0” if no cases seen.
Category I (Immediately Notifiable) Category II (Weekly Notifiable)
_____ Acute Flaccid Paralysis0 _____ Acute Bloody Diarrhea0

_____ Adverse Event Following Immunization (AEFI)0 _____ Acute Encephalitis Syndrome0
_____ Anthrax0 _____ Acute Hemorrhagic Fever Syndrome0
_____ Human Avian Influenza0 _____ Acute Viral Hepatitis0
_____ Measles
0 _____ Bacterial Meningitis0
_____ Meningococcal Disease0 _____ Cholera0
_____ Neonatal Tetanus0 _____ Dengue11
_____ Paralytic Shellfish Poisoning0 _____ Diphtheria0
_____ Rabies1 _____ Hand, Foot and Mouth Disease (HFMD) 1
_____ Severe Acute Respiratory Syndrome0 _____ Influenza-like Illness0
(SARS) _____ Leptospirosis1
_____ Outbreaks _____ Malaria0
_____ Non-neonatal Tetanus0
• Clusters of diseases _____ Pertussis0
• Unusual diseases or threats _____ Typhoid and Paratyphoid Fever0
Category I: Notify simultaneously the PHO, CHD and NEC within 24 hours of detection and send advance
copy of the Case Investigation Form (CIF) as soon as possible.
Category II: Report all cases of notifiable diseases/syndromes every FRIDAY of the week to the next higher
level
“Let’s help prevent epidemics”
Annex 3:
The PIDSR Case Investigation Forms
The following pages are the PIDSR Case Investigation Forms for the Category I (Immediately Notifiable)
diseases, syndromes and health events which include the following:
 Acute Flaccid Paralysis
 Adverse Event Following Immunization
 Anthrax
 Human Avian Influenza
 Measles
 Meningococcal Disease
 Neonatal Tetanus
 Paralytic Shellfish Poisoning
 Rabies
 Severe Acute Respiratory Syndrome (SARS)
As their name imply, the forms will be used to obtain relevant information on every case seen in the health
facility. The variables included are highly significant as they will become bases for the following:
 The diagnosis of the illness.
 The analysis of all surveillance data by person, place and time.
 The presence of an outbreak in a particular period of time in a particular geographic area.
 The weekly reporting that your health facility will submit to the next higher health service level.
 The promptness and type of public health action.
It is therefore imperative that each case in Category I diseases, syndromes or health event will have his
own PIDSR Case Investigation Form and that every sheet is accomplished completely. Failure to do so will
prompt the next health service level to contact you or your staff to complete the forms. Failure would also
lead to an error in analysis of the surveillance data, generation of wrong conclusions and giving out of
wrong recommendations.
A review of the individual forms will be part of the monitoring and evaluation activities.
Annex 4:
The PIDSR Case Report Forms
The following pages are the PIDSR Case Report Forms for the Category II (Weekly Notifiable) diseases,
syndromes and health events which include the following:
 Acute Bloody Diarrhea
 Acute Encephalitis Syndrome
 Acute Hemorrhagic Fever Syndrome
 Acute Viral Hepatitis
 Bacterial Meningitis
 Cholera  Dengue
 Diphtheria
 Hand-Foot-Mouth Disease
 Influenza-like Illness
 Leptospirosis
 Malaria
 Non-Neonatal Tetanus
 Pertussis
 Typhoid and Paratyphoid Fever
Date onset: _____/_____/_____ Right arm:  Y  N  U
Fever:  Y  N  U Present at birth?:  Y  N  U Left arm:  Y  N  U
Cough:  Y  N  U Asymmetric?:  Y  N  U
Right leg:  Y  N  U
Diarrhea/Vomiting:
PROGRESSION Left leg:  Y N U Y
N U
Paralysis fully developed within 3Breathing muscles:  Y  N  U
Muscle pain: to 14 days from onset of illness?
 Y N U Neck muscles:  Y  N  U
 Y N U
Meningeal signs: Facial muscles:  Y N U
 Y N U Direction of paralysis:
Working / final Diagnosis: _______
 Ascending  Descending
_____________________________
 Unknown
III. EPIDEMIOLOGIC DATA
History of neurologic disorder?:  Y  N  U If YES, specify disorder:_________________________________
Did the patient travel in another province, city or country within 60 days prior to onset of paralysis?  Y  N  U
If YES, specify place:____________________________________
Other AFP cases in patient’s community within 60 days of patient’s paralysis?  Y  N  U
Does the patient had any history of injection, fall, trauma and/ or animal bite ?  Y  N  U If YES, specify : __________________________
Total OPV doses received: _______ Date last dose of OPV : _____/_____/_____
VI. 60-DAY FOLLOW-UP
Expected date of follow-up:_____/_____/_____ Actual date of follow-up conducted:_____/_____/_____
P.E. done?  Y  N If NO, reason for no examination:  Patient died  Lost to follow-up  Other, specify____________________
Residual paralysis at 60 days?:  Y  N  UAtrophy?:  Y  N  U
Other observations:_____________________________________________
Case Investigation Form
Acute Flaccid Paralysis
VII. CLASSIFICATION (TO BE FILLED UP BY THE EXPERT PANEL ONLY)
FINAL CLASSIFICATION IF VAPP CLASSIFICATION CRITERIA FINAL DIAGNOSIS
 Confirmed wild polio  Recipient VAPP  Laboratory
 Vaccine-derived poliovirus (VDPV)  Contact VAPP  Lost to follow-up
 Vaccine-associated paralytic polio (VAPP)  Unknown  Death
 Polio-compatible  With residual paralysis
 Discarded non-polio AFP  Without residual paralysis
 Not AFP
Date classified: _____/_____/_____
Adverse Event Following Immunization
V. CAUSALITY ASSESSMENT AND FINAL DIAGNOSIS: (TO BE FILLED UP AFTER CLASSIFICATION BY THE BOARD)
What is the cause of AEFI? If program-error, was it due to
 Program-error Vaccine reaction  non-sterile injection  vaccine prepared incorrectly
 Coincidental  Unknown  wrong administration technique
 Injection Reaction 
improper vaccine transport or storage
Final diagnosis:___________________________________  Other, specify______________________________________ VI.
OUTCOME:
Outcome:  Alive Patient sustained disability?  Yes No Unknown

If YES, specify type of disability:__________________________________________
 DiedDate died: ____/____/____
 Unknown
Definition of Terms:
• AEFI is any untoward medical occurrence which follows immunization and which does not necessarily have a causal relationship with the
usage of the vaccine. The adverse event may be any unfavourable or unintended sign, abnormal laboratory finding, symptom or disease.
• A cluster of AEFI is defined as two or more cases of the same adverse event related in time, place or vaccine administered.
• Serious medical condition is defined as those that are life-threatening and those that result in hospitalization (or prolonged hospitalization),
disability (or have the potential to result in disability) or death.
LOCAL ADVERSE EVENTS:
• Injection-Site Abscess: Occurrence of a fluctuant or draining fluid-filled lesion at the site of injection with or without fever.
• Lymphadenitis (includes suppurative lymphadenitis): Occurrence of either: at least one lymph node, 1.5 cm in size (one adult finger
width) or larger; or a draining sinus over a lymph node. Almost exclusively caused by BCG and then occurring within 2 to 6 months after
receipt of BCG vaccine, on the same side as inoculation (mostly axillary).
• Severe local reaction: Redness and/or swelling centered at the site of injection and one or more of the following: swelling beyond the
nearest joint; pain, redness and swelling of more than 3 days duration; or requires hospitalization.
CENTRAL NERVOUS SYSTEM ADVERSE EVENTS:
• Acute Paralysis
 Acute onset of flaccid paralysis within 4 to 30 days of receipt of oral polio-virus vaccine (OPV), or within 4 -75 days after contact with a
vaccine recipient, with neurological deficits remaining 60 days after onset, or death.
 Guillain-Barré Syndrome (GBS): Acute onset of rapidly progressive, ascending, symmetrical flaccid paralysis, without fever at onset of
paralysis and with sensory loss. Cases are diagnosed by cerebrospinal fluid (CSF) investigation showing dissociation between cellular
count and protein content. GBS occurring within 30 days after immunization should be reported.
• Encephalopathy: Encephalopathy is an acute onset of major illness temporally linked with immunization and characterized by any two of the
following three conditions: Seizures; Severe alteration in level of consciousness lasting for one day or more; and Distinct change in behavior
lasting one day or more. Cases occurring within 72 hours after vaccination should be reported.
• Encephalitis: Encephalitis is characterized by encephalopathy and signs of cerebral inflammation and, in many cases, CSF pleocytosis
and/or virus isolation. Any encephalitis occurring within 1 to 4 weeks following immunization should be reported.
• Meningitis: Acute onset of major illness with fever, neck stiffness/positive meningeal signs (Kernig, Brudzinski). Symptoms may be subtle to
similar to those of encephalitis. CSF examination is the most important diagnostic measure: CSF pleocytosis and/or detection of
microorganism (Gram stain or isolation).
• Seizures: Seizures lasting from several minutes to more than 15 minutes and not accompanied by focal neurological signs or symptoms.
Febrile Seizures or Afebrile Seizures. Onset is usually 0 to 2 days.
OTHER ADVERSE EVENTS:
• Anaphylactoid Reaction (acute hypersensitivity reaction): Exaggerated acute reaction, occurring within 2 hours after immunization,
characterized by one or more of the following: (1) wheezing and shortness of breath due to bronchospasm; (2) laryngospasm/laryngeal
edema; (3) one or more skin manifestations, e.g. hives, facial edema, or generalized edema.
• Anaphylactic Shock: Circulatory failure (e.g. alteration of the level of consciousness, low arterial blood pressure, weakness or absence of
peripheral pulses, cold extremities secondary to reduced peripheral circulation, flushed face and increased perspiration) with or without
bronchospasm and/or laryngospasm/laryngeal edema leading to respiratory distress occurring immediately (0 to1 hr) after immunization.
• Neuritis: Dysfunction of nerves supplying the arm/shoulder/gluteal area without other involvement of nervous system. A deep steady, often
severe aching pain in the shoulder and upper arm or gluteal area followed in days or weakness by weakness and wasting in arm/shoulder/
gluteal muscles. Sensory loss may be present, but is less prominent. May present on the same or the opposite side to the injection and
sometimes affects both arms or gluteal area. Onset is usually 2 to 28 days.
• Disseminated BCG infection: Disseminated infection occurring within 1 to 12 months after BCG vaccination and confirmed by isolation of
Mycobacterium bovis BCG strain.
• Hypotensive-Hyporesponsive Episode (shock collapse): Sudden onset of paleness, decreased level or loss of responsiveness,
decreased level or loss of muscle tone (occurring within 24 hours of vaccination). The episode is transient and self-limiting.
• Osteitis/Osteomyelitis: Inflammation of the bone either due to BCG immunization (occurring within 8 to 16 months after immunization) or
caused by other bacterial infection.
• Persistent Screaming: Inconsolable continuous crying lasting at least 3 hours accompanied by high-pitched screaming. Onset 0 to 24 hrs.
• Sepsis: Acute onset of severe generalized illness due to bacterial infection and confirmed by positive blood culture.
• Thrombocytopenia: Platelet count of 100,000 cells or less per mm3. Onset is 15 to 35 days.
• Toxic-Shock Syndrome: Abrupt onset of fever, vomiting and watery diarrhea within a few hours of immunization, often leading to death
within 24-48 hours.
Philippine Integrated Disease Surveillance and Response
Anthrax
(ICD 10 Code: A22)
Name of DRU:
Address: Type: RHU CHO Gov’t Hospital Private Hospital Clinic
Gov’t Laboratory Private Laboratory Airport/Seaport
I. PATIENT Patient Number: ere Patient’s First Name Middle Name Last Name
INFORMATION:
Complete Address: MM DD YY Age:

Date Days
Male
Sex: of Months
Female
Birth: Years
District: ILHZ:
Occupation: Name Workplace:
Address of Workplace:
II. CLINICAL Admitted? Date Admitted/ MM DD YY Date Onset of MM DD YY
INFORMATION: Yes No Unknown Seen/Consult Illness
 Fever  Stomach pain  Neck pain

 Upset stomach  Vomiting blood  Itchy skin
(nausea)  Bloody diarrhea  Black scab on skin
 Headache  Dry  Sweating excessively  Skin lesions
Signs and cough  Extreme tiredness Describe lesion: ____________
Symptoms:  Sore throat  Pain or tightness in the chest _________________________
 Trouble swallowing  Sore muscles  Other (list): ________________
 Trouble breathing _________________________
III. POTENTIAL RISK FACTORS IN THE 15-60 DAYS PRIOR TO ONSET OF SIGNS/SYMPTOMS
 Y N U Is the patient’s occupation associated with animals or agriculture?

 Y N U Has the patient been exposed to Anthrax Vaccine or to anthrax-vaccinated animals?
 Y N U Does the patient have occupational or other exposure to hides, wool, furs, bone meal or other animal
products?
 Y N U Contact with live or dead animals? (cattle, sheep, goats, horses, pigs and other herbivores both livestock and wildlife) 
Y N U Does the patient have a history of travel beyond his/her usual place of residence/surroundings?  Y N
U Does the patient work in a laboratory?
 Y N U Have any household members experienced similar symptoms recently?
 Y N U Has the patient eaten undercooked meat? (cattle, sheep, goats, horses, pigs and other herbivores both livestock and
wildlife)  Y N U Did the patient receive unusual letters or packages? (e.g. containing threats or unusual messages)  Y
 N U Has the patient opened mails for others?
 Y N U Was the patient present or nearby when an envelope that contained any form of powder was opened?
IV. CLINICAL FORMS, CLASSIFICATION AND OUTCOME:

CLINICAL FORMS CASE CLASSIFICATION OUTCOME
 Cutaneous
 Gastrointestinal
 Alive
 Pulmonary  Suspected Case
 Probable Case  Died, Date died:
 Meningeal ____/____/____
 Unknown  Confirmed Case  Unknown
V. LABORATORY TESTS:
Specify If YES, date Type of laboratory Results
Specimen taken test done N=Negative; I=Indeterminate; U-Unknown Date result
MM DD YY MM DD YY
Positive for: N I U
MM DD YY MM DD YY
Positive for: N I U
Philippine Integrated Disease Surveillance and Response

Anthrax
(ICD 10 Code: A22)
CASE DEFINITION/CLASSIFICATION:
Suspected Case:
An illness suggestive of one of the known anthrax clinical forms as described above. No definitive, presumptive, or suggestive
laboratory evidence of Bacillus anthracis, or epidemiologic evidence relating it to anthrax
a) Cutaneous Anthrax:
An acute illness, or post-mortem examination revealing a painless skin lesion developing over 2 to 6 days from a
papular through a vesicular stage into a depressed black eschar with surrounding edema. Fever, malaise and
lymphadenopathy may accompany the lesion.
b) Inhalation Anthrax:
An acute illness, or post-mortem examination revealing a prodrome resembling a viral respiratory illness, followed
by hypoxia, dyspnea or acute respiratory distress with resulting cyanosis and shock. Radiological evidence of
mediastinal widening or pleural effusion is common.
c) Gastrointestinal Anthrax:
An acute illness, or post-mortem examination revealing severe abdominal pain and tenderness, nausea, vomiting,
hematemesis, bloody diarrhea, anorexia, fever, abdominal swelling and septicemia.
d) Oropharyngeal Anthrax:
An acute illness, or post-mortem examination revealing a painless mucosal lesion in the oral cavity or oropharynx,
with cervical adenopathy, edema, pharyngitis, fever, and possibly septicemia.
e) Meningeal Anthrax:
An acute illness, or post-mortem examination revealing fever, convulsions, coma, or meningeal signs. Signs of
another form will likely be evident as this syndrome is usually secondary to the above syndromes.
Probable Case:
A clinically compatible illness that does not meet the confirmed case definition, but with one of the following:
 Epidemiological link to a documented anthrax environmental exposure;
 Evidence of B. anthracis in clinical specimens collected from a normally sterile site (such as blood or cerebrospinal fluid
[CSF]) or lesion of other affected tissue (skin, pulmonary, reticuloendothelial, or gastrointestinal)
Confirmed Case:
A clinically compatible illness with one of the following:
 Culture and identification of B. anthracis from clinical specimens
 Demonstration of B. anthracis antigens in tissues by immunohistochemical staining using both B. anthracis cell wall and
capsule monoclonal antibodies;
Documented anthrax environmental exposure AND evidence of B. anthracis DNA in clinical specimens collected from a
normally sterile site (such as blood or CSF) or lesion of other affected tissue (skin, pulmonary, reticuloendothelial, or
gastrointestinal).
Philippine Integrated Disease Measles-Rubella
Surveillance and Response
(ICD 10 Code: B05; B06)
Name of DRU:
Type: RHU CHO Gov’t Hospital Private Hospital Clinic
DRU Complete Address: Gov’t Laboratory Private Laboratory Airport/Seaport

I. PATIENT INFORMATION
Patient Number EPI ID Patient’s First Name Middle Name Last Name
HANIE AMARA GALANG BINOYA
Date of Birth: 1
Complete Address: Sex:  Male  Female Age: ________
Pregnant? Y  N  U MM DD YY  Days
P7, SALAZA, PALAUIG, ZAMBALES If Yes, weeks of pregnancy ______ 05____/____/____ 28 2020   MonthsYears
District: ILHZ: Patient admitted?  Y  N Date Admitted/ MM DD YY
Seen/Consult 06 25 2022
Name of parent/caregiver: HAROLD ISIDRO BINOYA Contact Nos.: 09701712869
MM DD YY
Date of Report: 06 26 22 Name of reporter: DALISAY SAHAGUN, RN, MAN Contact Nos.: 09205437110
Date of MM DD YY
Investigation: 06 26 22 Name of investigator/s: ANGELIE MAE A. ABELONContact Nos.: 09205437110 II.
CLINICAL DATA
Fever:  Y  N Arthralgia/arthritis:  Y N Are there any complications?

Date onset: ____/____/____06 23 2022Swollen lymphatic nodules:  Y  N  Y N
Rash:  Y  N If YES, specify: ________________
Date onset: ____/____/____06 24 2022If yes, specify location: Other symptoms:
Cough:  Y  N  cervical  sub-occipital _____________________________ Koplik sign:  Y  N 
post-auricular Working/Final Diagnosis:
Runny nose/coryza:  Y N  others, specify _____________________________ Red
eyes/conjunctivitis:  Y N _______________________________
III. VACCINATION HISTORY AND VITAMIN A SUPPLEMENTATION
Patient received measles-containing vaccine (MCV)?  Y  N
If Yes, indicate the number of doses whichever is applicable: MV___ MR___
MMR___
Date last dose received MCV: _____/_____/_____
Was vaccination received during special campaigns?  Y N
If patient did not receive any MCV, state the reason/s:
 Mother was busy  Child was sick  Forgot schedule
 Against belief  No vaccine available  Other reasons, specify
 Medical contraindication  Vaccinator not available _________________________
_
 Fear of side effects  Not eligible for vaccination
Was the patient given Vitamin A during this illness?  Y N
IV. EXPOSURE HISTORY
History of travel in another province, city or country: N Y If Yes: If YES, specify place:__________________________________
Date traveled: From_____/_____/_____ To _____/_____/_____
Indicate timing of travel relative to rash onset:
 <7 days from rash onset  7-21 days from rash onset  >21 days from rash onset
Tick the type of place where exposure probably occur: Day care Barangay Home School Health Care Facility
Dormitory  work place Others, specify ________________
*Was there contact with a measles/rubella case (or individual with rash and fever) 7-21 days prior to rash onset?  Y  N 
U
If YES, full name of contact: ______________________________________ Date of contact ___/___/____
Name of barangay & municipality/city :___________________________________________________________________
* Are there other known cases with fever and rash (regardless of presence of 3 C’s) in the community?  Y  N  U
* Note: If the answer to any of the last two questions is YES, coordinate with the ESU for validation and field investigation
Measles-Rubella Case Investigation Form
V. LABORATORY TESTS
Date received
Specimen collected in RITM (to be Measles IgM Rubella IgM Virus Isolation PCR
(Put  in the box filled up by Result Result Result Result
If YES, Date Date sent to
Provided) RITM)
Collected RITM
Serum ___ /___ /___ ___ /___ /___
Dried Blood Spot ___ /___ /___ ___ /___ /___
Oropharyngeal/
Nasopharyngeal swab? ___ /___ /___ ___ /___ /___
OraCol? ___ /___ /___ ___ /___ /___
VI. FINAL CLASSIFICATION VII. SOURCE OF INFECTION

 Laboratory confirmed measles  Laboratory confirmed rubella  Endemic
 Epi-linked confirmed measles  Epi-linked confirmed rubella  Imported
 Clinically Measles compatible  Discarded as non-measles/ non Vaccine-  Import-related
associated measles rubella  Unknown
VIII. OUTCOME:  Alive  Died  Unknown Date died:___/___/___

FINAL DIAGNOSIS: ______________________________________________
CASE DEFINITION
Suspected case: Any person with fever and maculopapular rash (non-vesicular) and either cough, coryza (runny nose) or
conjunctivitis (red eyes)
CLASSIFICATION
1. Laboratory-confirmed measles case: A suspected measles case that has been confirmed by the National Measles
Laboratory (NML) of the Re-search Institute for Tropical Medicine as positive for measles IgM antibodies and/or positive for measles virus
isolation or Polymerase Chain Reaction (PCR).
2. Epidemiologically linked confirmed measles case: A suspect measles case that has not been confirmed by a laboratory but
temporally and geographically related, with dates of rash onset occuring between 7-21 days apart, to a laboratory-confirmed case or, in
the event of a chain of transmission, to another epidemiologically-linked measles case.
3. Clinically measles compatible case: A suspect measles case for which no adequate specimen was taken and which has not
been linked epi-demiologically to a laboratory confirmed measles case or another laboratory-confirmed communicable disease.
4. Laboratory-confirmed rubella case: A suspected measles case that has been confirmed by the NML as positive for rubella
IgM antibodies.
5. Epidemiologically linked confirmed rubella case: A patient with a febrile rash illness that is negative for measles and
epidemiologically-linked to a laboratory-confirmed rubella case
6. Discarded as Non-measles and Non-Rubella: A suspect case that has been investigated and discarded as a non-measles
and nonrubella case using (1) laboratory testing by the NML or (2) epidemiological linkage to a laboratory-confirmed case/outbreak of
another communicable disease that is neither measles nor rubella.
LABORATORY CONFIRMATION:
• Positive serologic test result for anti-measles IgM antibodies
• Fourfold rise in anti-measles IgG antibodies in acute and convalescent serum  Isolation of measles virus
• Dot immunobinding assay
• Polymerase chain reaction testing for measles nucleic acid
Therapeutic Dosage of Vitamin A for Measles cases:
• 50,000 IU for children <6 months old
• 100,000 IU for children 6 to 11 months old  200,000 IU for children 12 to 71 months old
Note:
The therapeutic dosage of Vitamin A for measles cases should be given upon diagnosis regardless of when the last dose of vitamin A capsule
was given.
Philippine Integrated DiseaseSurveillance and Response Case Investigation Form
Meningococcal Disease
(ICD 10 Code: A39)
Name of DRU:
I. PATIENT Patient Number: Patient’s First Name Middle Name Last Name
INFORMATION:

Date Days
Male
Sex: of  Months
Female Birth: Years
District: ILHZ:
Occupation: Name Workplace:
Address of Workplace:
Name of School: Address of School:

If student:
II. CLINICAL Admitted? Date Admitted/ MM DD YY Date Onset MM DD YY
INFORMATION: Yes No Unknown Seen/Consult of Illness
Fever Seizure Malaise

Headache Stiff neck Cough
Signs and
Maculopapular rash Vomiting Sore throat
Symptoms: Petechia Change of sensorium Runny nose
Purpura Drowsiness Dyspnea
Other lesions: Other signs / symptoms:
Clinical Presentation: Case Classification: Outcome:
Meningitis Suspected Case Alive
Septicemia Probable Case Died, Date Died _____/_____/_____
Both Confirmed Case Unknown
III. CASE Were blood/CSF extracted before the first dose of antibiotics was given to the patient?
MANAGEMENT:
Yes No Unknown
What antibiotics were given in the hospital?
IV. LABORATORY TESTS:

If YES, date Type of laboratory Results
Specimen taken test done N=Negative; I=Indeterminate; U-Unknown; ND= Not Done Date result
MM DD YY MM DD YY
Culture Positive for: N I U ND
MM DD YY MM DD YY
CSF Latex agglutination Positive for: N I U ND
MM DD YY MM DD YY
Gram stain Positive for: N I U ND
MM DD YY MM DD YY
Blood Culture Positive for: N I U ND

Meningococcal Disease
V. PAST HISTORY: Did the PATIENT or CLOSE CONTACT/S interact with a suspected or confirmed meningococcal case
within 2 weeks before onset of illness?
Yes, the patient Yes, close contact/s (name/s) __________________________________________
No Unknown
If yes, what was the name of the suspected or confirmed meningococcal case?
What is the address of the suspected or confirmed meningococcal case?
Where did the patient or close contact/s interact with the meningococcal case? When? MM/DD/YY Number of Days?
Did the PATIENT travel within 2 weeks prior to illness? If yes, where?
Did a CLOSE CONTACT/S of the patient travel within 2 weeks prior to illness? If yes, who and where?
Did the PATIENT attend any social gathering within 2 weeks prior to illness? If yes, where?
Did the PATIENT have upper respiratory tract infection within 2 weeks prior to illness? Yes No Unknown
Did a CLOSE CONTACT/S have upper respiratory tract infection within 2 weeks prior to the patient’s illness?
Yes No Unknown, If Yes, who?
Philippine Integrated Disease Case Investigation Form
Neonatal Tetanus
Name of DRU:
INFORMATION:
Complete Address: MM DD YY Age in days:

 Male Date of
Sex:
 Female Birth:
District: ILHZ:
Patient Admitted?  Yes  No  Unknown Date Admitted/ MM DD YY Date Onset of MM DD YY
Seen/Consult Illness
MM DD YY MM DD YY Mother’s Full Name:
Date of Report: Date of Investigation:
II. CLINICAL DATA:

In the first 2 days of life did the baby has normal suck and cry? After 2 days of life, did the baby have body stiffness or muscle
 Yes  No  Unknown spasm?  Yes  No  Unknown
After 2 days of life, was the baby unable to suck and cry normally? Was the umbilical stump infected? (bad smell, pus)
 Yes  No  Unknown  Yes  No  Unknown
III. MOTHER’S INFORMATION:
Prenatal Care Immunization Status If she has a card, copy the dates of all
No. of total pregnancies:_____ How many doses of TT has the mother
TT immunizations recorded on the
Live births:_____ Living children:______
received?_____ doses ____unknown
How many prenatal care visits did the mother card:
Date last dose given:_____/____/_____
make to a health facility during her pregnancy? TT1:_____/_____/_____
If she received 2 doses, were they given during
TT2:_____/_____/_____
______ this pregnancy?  Y  N  U
TT3:_____/_____/_____
When was the first prenatal visit?___/____/___ Is the immunization status reported by:
TT4:_____/_____/_____
Is the prenatal care history reported by:  Card  Recall  Both  Unknown
TT5:_____/_____/_____
 Card  Recall  Both  Unknown
Is the child protected at birth*?
State reason for no or late prenatal
 Yes  No  Unknown
care:________________________________
IV. DELIVERY PRACTICES:

Place of delivery:  Home  Hospital/lying-in/clinic  Other, specify: ______________________________________ If
born in a hospital/lying-in/clinic, give name and address of the hospital/lying-in/clinic: __________________________________
Who attended the delivery?  Physician  Nurse  MIdwife
 Hilot  Unknown  Other, specify:________________________________________ Cord was cut using:  Scissors 
Blade
 Bamboo  Unknown  Other, specify:__________________________
If Hilot, was he/she trained?  Yes  No  Unknown
Stump treated (dressed) with:  Alcohol  Povidone iodine
 Unknown  Other, specify:__________________________________________
V. CLASSIFICATION AND OUTCOME:

CASE CLASSIFICATION OUTCOME
 Suspected Case  Alive
 Confirmed Case  Died Date died: ____/____/____
 Unknown

Neonatal Tetanus
Paralytic Shellfish Poisoning
(ICD 10 Code: T61.2)
Name of DRU:
INFORMATION:

 Days
 Male Date of
Sex:  Months
 Female Birth:
District: ILHZ:  Years

II. EXPOSURE HISTORY:

Specify place where suspected shellfish was harvested:____________________________________________
Are there other members of household/community who shared the same meal?  Yes  No  Unknown
III. CLASSIFICATION AND OUTCOME:

FINAL CLASSIFICATION OUTCOME
 Unknown
Name of DRU:
INFORMATION:
Complete Address:  Male Date of MM DD YY Age:  Days

Sex:  Female Birth:  Months
 Years


 Unknown
CASE DEFINITION/CLASSIFICATION: • Probable Case: Not applicable

• Suspected case: A person who develops one or • Confirmed case: A suspected case in which
more of the following signs and symptoms after laboratory tests (biologic or environmental)
taking shellfish meal or soup: have confirmed exposure.
Sensory : paresthesias (tingling sensations on skin), LABORATORY CONFIRMATION:
numbness (lack of sensation) of the oral mucosa • Detection of saxitoxin in epidemiologically
and lips, implicated food, serum or urine of cases
numbness of the extremities
Motor: difficulty in speaking, swallowing, or
breathing, weakness or paralysis of the extremities
(Please use the back page)
Paralytic Shellfish Poisoning
(ICD 10 Code: T61.2)
Name of DRU:
INFORMATION:

 Days
 Male Date of
Sex:  Months
 Female Birth:
District: ILHZ:  Years
Patient Admitted?  Yes  No  Date Admitted/ MM DD YY Date Onset of MM DD YY

Unknown Seen/Consult Illness


 Unknown
Name of DRU:
Type: RHU CHO Gov’t Hospital Private Hospital Clinic
Address:
:
INFORMATION
Complete Address: MM DD YY Age:  Days

Male Date of
Sex:   Months
 Female Birth:
 Years
Patient Admitted? Yes  No  Unknown MM DD YY MM DD YY
Date Admitted/ Date Onset of Ill-
Seen/Consult ness

Are there other members of household/community who shared the same meal?
 Yes  No  Unknown


 Unknown
Philippine Integrated DiseaseSurveillance and Response Case Investigation Form
Rabies
• Suspected Case: A person presenting with an
acute neurological syndrome (encephalitis)
dominated by forms of hyperactivity (furious rabies)
or paralytic syndromes (dumb rabies) that
progresses towards coma and death, usually by
respiratory failure, within 7 to 10 days after the first
symptom if no intensive care is instituted.
• Probable case: A suspected case plus history of
contact with suspected rabid animal.
Note: Bites or scratches from a suspected animal can
usually be traced back in the patient medical history. The
incubation period may vary from days to years but usually
falls between 30 and 90 days.
• Confirmed case: A suspected case that is
laboratory confirmed.
LABORATORY CONFIRMATION:
One or more of the following:
• Detection of rabies viral antigens by direct
fluorescent antibody (FA) in clinical specimens,
preferably brain tissue (collected post mortem);
• Detection by FA on skin or corneal smear (collected
ante mortem);
• FA positive after inoculation of brain tissue, saliva or
CSF in cell culture, in mice or in suckling mice;
• Detectable rabies-neutralizing antibody titer in the
CSF of an unvaccinated person;
• Identification of viral antigens by PCR on fixed
tissue collected post mortem or in a clinical
specimen (brain tissue or skin, cornea or saliva);
• Isolation of rabies virus from clinical specimens and
confirmation of rabies viral antigens by direct
fluorescent antibody testing.
Philippine Integrated Disease Case Report Form
Surveillance and Response Acute Bloody Diarrhea
Region: ____________________________ Province: ___________________________ Municipality/City: ________________________________________
Name of DRU: _________________________________________________________________ Type: ⃞RHU ⃞CHO ⃞Gov’t Hospital ⃞Private Hospital ⃞Clinic Address:
______________________________________________________ ⃞Private Laboratory ⃞Public Laboratory ⃞Seaport/Airport
Date
Admitted Date onset Out-
Patient No. Patient’s Full Name Age Sex Date of Birth Complete Address Admitted/seen/ Lab result
? of illness come
consulted
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

Age: Indicate P-
D - days Positive A-
M - months (specify Alive
Response Yr. - years organism) D - Died
Indicate First name, Middle Specify Street/Purok/Subdivision, House #, Barangay, Y - Yes N-
Codes / Sex:F - mm/dd/yy mm/dd/yy mm/dd/yy N- (specify
name, Last name Municipality/City, Province No
Instructions Female M - Negative date)
Male ND - Not U-
done Unknown
U - Unknown
Case Definition:
 A person with acute diarrhea with visible blood in the stool.
Note: Laboratory culture of stools may be used to confirm possible outbreaks of specific diarrhea, such as S. dysenteriae type 1, but is not necessary for case definition.
 Case classification: Not applicable
Philippine Integrated Disease Case Report Form Surveillance and Response Acute Bloody Diarrhea
Date
Patient No. Patient’s Full Name Age Sex Date of Birth Complete Address Admitted/seen/ Lab result
? of illness come
consulted
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

Response Indicate First name, Middle Age: Indicate mm/dd/yy Specify Street/Purok/Subdivision, House #, Barangay, Y - Yes N- mm/dd/yy mm/dd/yy P - Positive
A-
Codes / name, Last name D - days Municipality/City, Province No (specify
Alive
Instructions M - months organism)
N- D - Died
Yr. - years
Negative (specify
Sex:F -
ND - Not date)
Female M -
done U - U-
Male
Unknown
Unknown
Acute Encephalitis Syndrome (ICD 10 Code: A83.0)
Date
Patient Patient’s Full Date of Date onset Lab Case Out-
Age Sex Complete Address Admitted? Admitted/seen/
No. Name Birth of illness Result Classification come
consulted
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

Age: Indicate P- A-
D - days Positive Alive
M - months (specify Suspected AE - D - Died
Response Yr. - years organism) other (specify
Indicate First name, Specify Street/Purok/Subdivision,
Codes / Sex: F - N- agent date)
Middle name, Last mm/dd/yy House #, Barangay, Municipality/City, Y - Yes N- No mm/dd/yy mm/dd/yy
Instruction
name
Female
Province
Negative AE - unknown U-
s M - Male ND - Not Probable JE Unknown
done Confirmed
U-
Unknown
Case Definition/Classification: Laboratory-confirmed JE: an AES case that has been laboratory-
AES (Suspected JE) Case: a case of Acute Encephalitis Syndrome (AES) is confirmed as JE.
defined as a person of any age, with the acute onset of fever and at least
one of the following : AES - other agent: an AES case in which diagnostic testing is performed
 Change in mental status (e.g.confusion, disorientation, coma or inabil- and an etiologic agent other than JE virus is identified. ity to
talk);
 New onset of seizures (excluding simple febrile seizures). AES - unknown: an AES case in which testing was performed but no
etiologic agent was identified or in which the test results were indeterminate.
Clinical case: a case that meets the suspect case definition.
Laboratory Confirmation:
Probable JE: an AES case that occurs in close geographical and temporal rela-  Presence of JE virus-specific IgM antibody in a single sample of ceretionship to
a laboratory-confirmed case of JE, in the context of an outbreak. brospinal fluid (CSF) or serum, as detected by an IgM-capture ELISA
Surveillance and Response Acute Encephalitis Syndrome (ICD 10 Code: A83.0)
Date
Patient Patient’s Full Date of Date onset Lab Case Out-
Age Sex Complete Address Admitted? Admitted/seen/
No. Name Birth of illness Result Classification come
consulted
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

Response Indicate First name, Age: Indicate mm/dd/yy Specify Street/Purok/Subdivision, Y - Yes N- mm/dd/yy mm/dd/yy P- Suspected AE - A-
Codes / Middle name, Last D - days House #, Barangay, Municipality/City, No Positive other Alive
Instruction name M - months Province (specify agent D - Died
s Yr. - years organism) (specify
AE - unknown
Sex: F - N- date)
Probable JE
Female Negative Confirmed U-
M - Male ND - Not Unknown
done
U-
Unknown

Acute Hemorrhagic Fever Syndrome
Date Blood
Patient Date of Admitted Date onset PCR Out-
Patient’s Full Name Age Sex Complete Address ?
Admitted/seen/ Culture
No. Birth of illness Result come
consulted Result
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___
P-
P - Positive
Positive
Age: Indicate (specify
(specify A - Alive
D - days organism)
organism) D - Died
Response M - months N-
Indicate First name, Middle Specify Street/Purok/Subdivision, House Y - Yes N- N- (specify
Codes / Yr. - years mm/dd/yy mm/dd/yy mm/dd/yy Negative
name, Last name #, Barangay, Municipality/City, Province No Negative date)
Instructions Sex:F - ND - Not
ND - Not U-
Female M - done
done Unknown
Male U-
U-
Unknown
Unknown
Case Definition:
 Any hospitalized person with acute onset of fever of less than 3 weeks duration Note: Laboratory confirmation should be done if available and
with any two of the following: hemorrhagic or purpuric rash, epistaxis, he-
matemesis, hemoptysis, blood in stools, or other hemorrhagic symptom and the Case classification: Not applicable diagnosis
is not Dengue
Philippine Integrated Disease Case Report Form Surveillance and Response Acute Hemorrhagic Fever Syndrome
Date Blood
Patient Date of Admitted Date onset PCR Out-
Patient’s Full Name Age Sex Complete Address Admitted/seen/ Culture
No. Birth ? of illness Result come
consulted Result
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

P-
P - Positive
Positive
Age: Indicate (specify A-
(specify
D - days organism) Alive
organism)
Response M - months N- D - Died
Indicate First name, Middle Specify Street/Purok/Subdivision, House Y - Yes N- N-
Codes / Yr. - years mm/dd/yy mm/dd/yy mm/dd/yy Negative (specify
name, Last name #, Barangay, Municipality/City, Province No Negative
Instructions Sex:F - ND - Not date)
ND - Not
Female M - done U-
done
Male U- Unknown
U-
Unknown
Unknown
Acute Viral Hepatitis (ICD 10 Code: B15-B17)
Region:____________________________ Province: ___________________________ Municipality/City: ________________________________________
Date
Admitted Date onset Laboratory Case Out-
Patient No. Patient’s Full Name Age Sex Date of Birth Complete Address admitted/seen/
? of illness Result Classification come
consulted
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

Age: Indicate A-
D - days Alive
Response M - months D - Died
Indicate First name, Middle Specify Street/Purok/Subdivision, House Y - Yes N- S-Suspect
Codes / Yr. - years mm/dd/yy mm/dd/yy mm/dd/yy Specify (specify
name, Last name #, Barangay, Municipality/City, Province No CConfirmed
Instructions Sex:F - date)
Female M U-
- Male Unknown
Case Definition/Classification: Laboratory Confirmation:

• Suspected case: A person with acute illness characterized by acute jaundice, dark urine,  Hepatitis A: Positive for IgM anti-HAV loss of appetite, body weakness, extreme fatigue,
and high upper quadrant tenderness.  Hepatitis B: Positive for Hepatitis B surface antigen (HBsAg) or Positive for IgM anti-
HBc
• Probable : Not applicable  Hepatitis C: Positive for anti-HCV
• Confirmed Case: A suspected case that is laboratory confirmed  Non-A, non-B: Negative for IgM anti-HAV and IgM anti-HBs (or HBsAg)
Acute Viral Hepatitis (ICD 10 Code: B15-B17)

Date Laborator
Admitted Date onset Case Out-
Patient No. Patient’s Full Name Age Sex Date of Birth Complete Address admitted/seen/ y
? of illness Classification come
consulted Result
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

Response Indicate First name, Middle Age: Indicate mm/dd/yy Specify Street/Purok/Subdivision, House Y - Yes N- mm/dd/yy mm/dd/yy Specify S-Suspect C- A-
Codes / name, Last name D - days #, Barangay, Municipality/City, Province No Confirmed Alive
Instructions M - months D - Died
Yr. - years (specify
Sex:F - date)
Female M U-
- Male Unknown

Surveillance and Response Bacterial Meningitis (ICD 10 Code: A87)
Name of DRU: _________________________________________________________________ Type: ⃞RHU ⃞CHO ⃞Private Hospital ⃞Gov’t Hospital ⃞Clinic Address:
Date Case
Admitted Date onset Laboratory Out-
Patient No. Patient’s Full Name Age Sex Date of Birth Complete Address Admitted/seen/ Classificatio
? of illness Result come
consulted n
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

Age: Indicate A-
Response D - days Alive
M - months Specify Street/Purok/Subdivision, S-Suspect D - Died
Codes / Indicate First name, Y - Yes N- Specify
Yr. - years mm/dd/yy House #, Barangay, Municipality/City, mm/dd/yy mm/dd/yy P-Probable (specify
Instruction Middle name, Last name No organism
Sex:F - Female Province CConfirmed date)
s M - Male U-
Unknown
Case Definition/Classification: Probable Case:

A suspected case with CSF examination showing at least one of the following:
Suspected Case: turbid appearance,

A person with sudden onset of fever (≥ 38.5oC rectal or 38oC axillary) and one of the following leukocytosis (>100 cells/ mm3) or, and/or signs:
leukocytosis (10-100 cells/ mm3) AND either an elevated protein (>100 mg/dl) or
neck stiffness, decreased glucose (<40mg/dl)
altered consciousness, or
other meningeal sign, such as bulging fontanelle, Kernig’s sign and/ or Brudzinski sign. Laboratory Confirmation:
 Culture or detection (i.e. by Gram stain or antigen detection methods) of a bacterial
Confirmed case: pathogen other than Neisseria meningitides.
A suspected case that is laboratory-confirmed . Note: Identified Neisseria meningitides cases shall be reported as confirmed Meningococcal
Disease
Bacterial Meningitis (ICD 10 Code: A87)

Date Case
Date onset Laboratory Out-
Patient No. Patient’s Full Name Age Sex Date of Birth Complete Address Admitted? Admitted/seen/ Classificatio
of illness Result come
consulted n
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

Response Indicate First name, Age: Indicate mm/dd/yy Specify Street/Purok/Subdivision, Y - Yes N- mm/dd/yy mm/dd/yy Specify S-Suspect A-
Codes / Middle name, Last name D - days House #, Barangay, Municipality/City, No organism P-Probable Alive
Instruction M - months Province CConfirmed D - Died
Yr. - years (specify
s
Sex:F - Female date)
M - Male U-
Unknown

Surveillance and Response Cholera (ICD 10 Code: A00)
Date Stool
Admitted Date onset Case Out-
Patient No. Patient’s Full Name Age Sex Date of Birth Complete Address Admitted/seen Culture
? of illness Classification come
/ consulted result
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

Age: Indicate P - Positive A-
D - days (specify Alive
Response M - months organism) D - Died
S-
Codes / Indicate First name, Yr. - years Specify Street/Purok/Subdivision, House #, Y - Yes N- N - Negative (specify
mm/dd/yy mm/dd/yy mm/dd/yy Suspect
Instruction Middle name, Last name Sex:F - Female Barangay, Municipality/City, Province No ND - Not date)
CConfirmed
s M - Male done U-
U- Unknown
Unknown
Case Definition/Classification:
• Probable: Not applicable
• Suspected case:
• Confirmed case: A suspected case that is laboratory-confirmed
 Disease unknown in the area: A person aged 5 years or more with severe
dehydration or who died from acute watery diarrhea, OR
Laboratory Confirmation of
Cholera:  Disease endemic in the area: A person aged 5 years or more with acute watery diarrhea with or without vomiting, OR
 Isolation of Vibrio cholerae 01 or 0139 from stools in any patient with diarrhea
 In an area where there is a cholera epidemic: A person with acute watery diarrhea,
with or without vomiting.
Cholera (ICD 10 Code: A00)

Date Stool Case
Patient No. Patient’s Full Name Age Sex Date of Birth Complete Address Admitted/seen/ Culture Classificatio
? of illness come
consulted result n
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___

Age: Indicate P - Positive A-
D - days (specify Alive
M - months organism) D - Died
Response
Yr. - years N- S- (specify
Codes / Indicate First name, Specify Street/Purok/Subdivision, House #, Y - Yes N-
Sex:F - mm/dd/yy mm/dd/yy mm/dd/yy Negative Suspect date)
Instruction Middle name, Last name Barangay, Municipality/City, Province No
Female M ND - Not CConfirmed U-
s
- Male done Unknown
U-
Unknown
Surveillance and Response Dengue (ICD 10 Code: A90-A91)
Region: ____________________________3 Province: ___________________________Zambales Municipality/City: ________________________________________Iba
Name of DRU:_________________________________________________________________ President Ramon Magsaysay Memorial Hospital Type: ⃞RHU
⃞CHO ⃞Gov’t Hospital ⃞Private Hospital ⃞Clinic Address: ______________________________________________________ Purok 4, Palanginan,
Iba, Zambales ⃞Private Laboratory ⃞Public Laboratory ⃞Seaport/Airport
Admitted Date
Patient Sex ? Date onset of Case Out-
Patient’s Full Name Age Date of Birth Complete Address admitted/seen/
illness
Type
classification come
No. (F/M)
consulted
05 11 ___/___/___06 ___/___/___06
1 MERINDO, ABELYN SISON 10 F 2012___/___/___ P1, BANGCOL, STA CRUZ, ZAMBALES Y 28 22 23 22 S/DF P A
BARNACHEA, JUSTINE 10 08
PUROK 4, BANGANTALINGA, IBA, ___/___/___06 ___/___/___06
25
2 HERMAINE M. 14 F 2007___/___/___ ZAMBALES Y 28 22 22 W/DF P A
01 25 06 29 06 25
3 HUERTA, JOSHUA RAMIL 21 M 2001___/___/___ PALANGINAN, IBA, ZAMBALES Y 2001___/___/___2022___/___/___ W/DF S A
10 01 2004 06 29 2022 06 27 2022

4 YAON, KENJIE PANOL 7 M ___/___/___ PUROK 5, AMUNGAN, IBA, ZAMBALES Y ___/___/___ ___/___/___ W/DHF P A
EDEJER, JAN AIZER 06 09 PUROK 4, BULAWEN, PALAUIG, 06 30 06 29 2022

5 PADIOS 13 M 2009___/___/___ ZAMBALES Y 2022___/___/___ ___/___/___ W/DF S A
W—with A - Alive
Age: Indicate warning
D - days signs S - Suspect D - Died
Response (specify
Indicate First name, Middle M - months Specify Street/Purok/Subdivision, House Y - Yes N- N– no P - Probable
Codes / mm/dd/yy mm/dd/yy mm/dd/yy warning date) U
name, Last name Yr. - years #, Barangay, Municipality/City, Province No C - Con-
Instructions signs -
Sex:F - Female firmed
S-Severe Unknow
M - Male Dengue n
Severe Dengue
Clinical Case Definition/Classification: Dengue with Warning Signs
Dengue without Warning signs.
 Suspect ,A previously well person with acute febrile illness of 2-7 days durationplus A previously well person with acute febrile illness of 2-7 daysduration and
any of the clinical manifestations for dengue with or
A previously well person with acute febrile illness of 2-7 days durationplus two of the following: any one of the following: without warning signs,
Plus any of the following:
Headache, Body malaise, Myalgia, Arthralgia, Retro-orbital - Abdominal pain or tenderness Severe plasma leakage leading to
pain, Anorexia, Nausea, Vomiting, Diarrhea, Flushed skin, - Persistent vomiting - Shock
Rash ( petecheal, Herman’s sign)
- Clinical signs of fluid accumulation - Fluid accumulation with respiratory distress
 Probable - Mucosal bleeding Severe bleeding
A suspect case plus:
- Lethargy, restlessness Severe organ impairment
Laboratory test, at least CBC (leucopenia with or without
- Liver enlargement
thrombocytopenia) and/or Dengue NS1, antigen test or - Liver: AST or ALT >1000
dengue IgM antibody test (optional) - Laboratory: increase in Hct and/or decreasing platelet count - CNS: e.g. seizures, impaired consciousness
 Confirmed: - Heart: e.g. myocarditis
- Viral culture isolation, - Kidneys: e.g. renal failure
- Polymerase Chain Reaction
Dengue (ICD 10 Code: A90-A91)

Admitted Date Case-
Patient Sex ? Date onset of Out-
Patient’s Full Name Age Date of Birth Complete Address admitted/seen/ Type Classifi
No. (F/M)
consulted
illness
cation
come
11 04 06 30 06 27 2022
6 GIRON, MERCY MANALO 53 F 1968___/___/___ PUROK 12, AMUNGAN, IBA, ZAMBALES Y 2022___/___/______/___/___ W/DF S A
06 30
SANTOS, ILONAH JANE 03 31 2022___/___/__ 06 24
7 OCENAR 28 F 1994___/___/___ PUROK 1, PACO, BOTOLAN, ZAMBALES Y _ 2022___/___/___ W/DF S A
11 14 1977 PUROK 6, MALOMA, SAN FELIPE, 06 30 2022 06 23 2022

8 DOCTOR, NIDA DELA CRUZ 44 F ___/___/___ ZAMBALES Y ___/___/___ ___/___/___ W/DF S A
01 17 2017 PUROK 2, SAN VICENTE, PALAUIG, 06 30 2022 06 27 2022

9 ANAUD, ZEIVIAN KAIZER 5 M ___/___/___ ZAMBALES Y ___/___/___ ___/___/___ W/DF P A
MENDOZA, KENDREI 04 05 2016 06 30 2022 06 29 2022

10 VINCENT 6 M ___/___/___ PUROK 3, BANCAL, BOTOLAN, ZAMBALES Y ___/___/___ ___/___/___ W/DF S A
2 06 30
ARANDA, HANNA MAE 09 01 2020 07 02 202 2022
11 RIVERA 2 F ___/___/___ PUROK 9, AMUNGAN, IBA, ZAMBALES Y ___/___/___ ___/___/___ W/DF P A
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
W - with S–
A-
Age: Indicate Warning Suspect
Alive
D - days signs P-
Response D - Died
Indicate First name, Middle M - months Specify Street/Purok/Subdivision, House #, Y - Yes N- N– no Probable
Codes / mm/dd/yy mm/dd/yy mm/dd/yy (specify
name, Last name Yr. - years Barangay, Municipality/City, Province No warning C–
Instructions date)
Sex:F - Female signs S— confirmed
Severe U-
M - Male
Unknown
Dengue

Surveillance and Response Diphtheria (ICD 10 Code: A36)
Patient No. Patient’s Full Name Age Sex Date of Birth Complete Address
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
Age: Indicate
D - days
Response
M - months
Codes / Indicate First name, Middle name, Last name mm/dd/yy Specify Street/Purok/Subdivision, House #, Barangay, Municipality/City, Province
Yr. - years
Instructions
Sex: F - Female
M - Male
Case Definition/Classification: Note: Persons with positive Corynebacterium diphtheriae cultures who do not meet the
Probable Case: a person with an illness of the upper respiratory tract characterized by laryngitis clinical description (i.e. asymptomatic carriers) should not be reported as probable or
or pharyngitis or tonsillitis, and adherent membranes on tonsils, pharynx and/or nose. confirmed diphtheria cases.
Confirmed Case: a probable case that is laboratory confirmed or linked epidemiologically to a Laboratory Confirmation:
laboratory-confirmed case.  Isolation of Corynebacterium diphtheriae from a clinical specimen
Philippine Integrated Disease Case Report Form Surveillance and Response Diphtheria (ICD 10
Code: A36)
No. of DPT
Admitted Date Admitted/ Date of onset Date of last Case
Patient’s Full Name ? seen/consulted
doses Outcome
of Illness DPT Classification
received?
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

0
A - Alive
1
Y - Yes P - Probable D - Died (specify
Response Codes / Instructions mm/dd/yy mm/dd/yy 2 mm/dd/yy
N- No C - Confirmed date)
3
U - Unknown
Unknown
Influenza-like Illness (ICD 10 Code: J11)
Date Lab.
Patient Date onset Out-
Patient’s Full Name Age Sex Date of Birth Complete Address admitted/seen/ Done/ Classification
No. of illness come
Admitted? consulted Result
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
Age: Indicate Isolation A-

PCR S - Suspect
D - days Alive
Response Serology; C - Confirmed
M - months Specify Street/Purok/Subdivision, House #, D - Died
Codes / Indicate First name, Y - Yes N- Specify SS - Suspect
Yr. - years mm/dd/yy Barangay, mm/dd/yy mm/dd/yy (specify
Instruction Middle name, Last name No organism SARS
Sex: Municipality/City, Province date)
s SAI - Suspect
F - Female U-
HAI
M - Male Unknown
Case Definition and Classification:  Suspected Human Avian Influenza: A suspect ILI case with exposure to sudden bird
deaths (sudden bird deaths in two or more households in a barangay or death of at least
• Suspected case: A person with sudden onset of fever of ≥38°C and cough or sore throat 3% of commercial flock increasing twice daily for 2-3 consecutive days) OR confirmed huin the
absence of other diagnoses. man avian influenza case.
• Probable case: Not applicable Note: In cases of Suspected SARS and Suspected HAI notify simultaneously the PHO,
CHD and NEC within 24 hours of detection.
• Confirmed case: A suspected case that is laboratory-confirmed (used mainly in epidemiol-
ogical investigation rather than surveillance). Laboratory Confirmation:
• Virus isolation or Polymerase Chain Reaction (PCR) of swab or aspirate from the sus-
• Suspected Severe Acute Respiratory Syndrome (SARS) case: A suspect ILI case with pected Individual or direct detection of influenza viral antigen or 4-fold rise in antibody titer exposure
to confirmed SARS case. between early and late serum.
Surveillance and Response Influenza-like Illness (ICD 10 Code: J11)
Lab.
Patient Date Date onset Out-
Patient’s Full Name Age Sex Date of Birth Complete Address Done/ Classification
No. Admitted admitted/seen/ of illness come
Result
? consulted
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
Age: Indicate Isolation A-

S - Suspect
D - days PCR Alive
Response C - Confirmed
M - months Serology; D - Died
Codes / Indicate First name, Specify Street/Purok/Subdivision, House #, Y - Yes N- SS - Suspect
Yr. - years mm/dd/yy mm/dd/yy mm/dd/yy Specify (specify
Instruction Middle name, Last name Barangay, Municipality/City, Province No SARS
Sex: organism date)
s SAI - Suspect
F - Female U-
HAI
M - Male Unknown

Surveillance and Response Leptospirosis (ICD 10 Code: A27)
Date Date of
Complete Admitted Case Out-
Patient No. Name Age Sex Date of Birth Occupation Admitted/Seen/ Onset of
Address ? Classification come
Consulted Illness
___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

Age: Indicate A-
D - days Alive
Response
Indicate First name, M - months S - Suspect D - Died
Codes / Indicate Specify Street/Purok/Subdivision, House #, Y - Yes N-
Middle name, Last Yr. - years mm/dd/yy mm/dd/yy mm/dd/yy C - Con- (specify
Instruction occupation Barangay, Municipality/City, Province No
name Sex:F - firmed date)
s
Female M - U-
Male Unknown
• Suspected case: A person who developed acute febrile illness with headache, myalgia Laboratory Confirmation:
and prostration associated with any of the following: conjunctival suffusion, meningeal
irritation, anuria or oliguria and/or proteinuria, jaundice, hemorrhages (from the intestines  Isolation (and typing) from blood or other clinical specimens through culture of
pathoor lungs), cardiac arrhythmia or failure, skin rash and other common symptoms that in- genic Leptospira clude nausea, vomiting, abdominal pain, diarrhea, arthralgia AFTER
exposure to infected
animals or an environment contaminated with animal urine (e.g. wading in flood waters,  Positive serology, preferably Microscopic Agglutination Test (MAT), using a range of
rice fields, drainage). Leptospira strains for antigens that should be representative of local strains
• Probable case: Not applicable
• Confirmed case: A suspected case that is laboratory confirmed
Philippine Integrated Disease Case Report Form Surveillance and Response Leptospirosis (ICD 10 Code: A27)
Date Date of
Occupatio Complete Admitted Case Out-
Patient No. Name Age Sex Date of Birth Admitted/Seen/ Onset of
n Address ? Classification come
Consulted Illness
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

Response Indicate First name, Age: Indicate mm/dd/yy Indicate Specify Street/Purok/Subdivision, House #, Y - Yes N- mm/dd/yy mm/dd/yy S - Suspect A-
Codes / Middle name, Last D - days occupation Barangay, Municipality/City, Province No C - Con- Alive D
Instruction name M - months firmed - Died
s Yr. - years (specify
Sex:F - date)
Female M - U-
Male Unknown

Surveillance and Response Malaria (ICD 10 Code: B50 - B54)
Date
Date of Admitted
Patient No. Patient’s Full Name Age Sex Occupation Complete Address Admitted/seen/
Birth ?
consulted
___/___/___ ___/___/___
___/___/___ ___/___/___
___/___/___ ___/___/___
___/___/___ ___/___/___
___/___/___ ___/___/___
Age: Indicate
D - days
Response
Indicate First name, Middle name, Last M - months Specify Street/Purok/Subdivision, House #, Barangay, Y - Yes N-
Codes / mm/dd/yy Specify occupation mm/dd/yy
name Yr. - years Municipality/City, Province No
Instructions
Sex:F - Female
M - Male
Case Definition/Classification: In areas WITHOUT access to laboratory-based diagnosis:
• Uncomplicated malaria: Signs and symptoms vary; most patients experience fever.
 Probable uncomplicated malaria case: A person with signs (fever, splenomegaly, aneSplenomegaly and anemia are common associated signs. Common but non-specific
mia) and/or symptoms (unexplained headache, back pain, chills, sweating, myalgia, nausymptoms include otherwise unexplained headache, back pain, chills, sweating, myalgia, sea,
vomiting) of malaria who receives anti-malarial treatment. nausea, vomiting.
• Probable severe malaria case: A person who requires hospitalization for symptoms
and  Severe malaria: Coma, generalized convulsions, hyperparasetemia, normocytic anemia, signs of severe malaria (coma, generalized convulsions, renal failure, hyperpyrexia,
circudisturbances in fluid, electrolyte, and acid-base balance, renal failure, hypoglycemia, hy- latory collapse/shock, spontaneous bleeding, and pulmonary edema) and receives
antiperpyrexia, hemoglobinuria, circulatory collapse/shock, spontaneous bleeding malarial treatment. (disseminated intravascular coagulation) and pulmonary edema.
• Probable malaria death: death of a patient diagnosed with probable severe malaria 
Laboratory confirmation: Demonstration of malaria parasites in blood films (mainly asexual forms)
(continued at the back)
Philippine Integrated Disease Case Report Form Surveillance and Response Malaria (ICD 10 Code: B50 - B54)
History of History of
Date onset of Travel Recent
Patient ‘s Full Name Type of Parasite Case Classification Outcome
illness (If YES, specify Blood
place) Transfusion
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
PU - Probable uncomplicated
Y = Yes
Indicate whether : Y = Yes PS - Probable severe
N = No
Plasmodium falciparum N = No PD - Probable malaria death A - Alive
U = Unknown
Plasmodium vivax U = Unknown AS - Asymptomatic malaria D - Died
Response Codes / Instructions mm/dd/yy NOTE: Blood
Plasmodium malariae NOTE: Travel CU - Confirmed uncomplicated (specify date)
transfusion 2
Plasmodium ovale refers to 2 weeks CS - Confirmed severe U - Unknown
weeks prior to
Mi - Mixed (specify) prior to illness CD - Confirmed malaria death
illness
TF - Treatment failure
(In areas WITH access to laboratory-based diagnosis)

• Asymptomatic malaria: A person with no recent history of symptoms and/or signs of malaria
who shows laboratory confirmation of parasitemia. disseminated intravascular coagulation, and pulmonary edema) and receives antimalarial
• Confirmed uncomplicated malaria case: A person with signs (fever, splenomegaly, treatment AND with laboratory confirmation of diagnosis (microscopy or
anemia) and/or symptoms (unexplained headache, back pain, chills, sweating, myalgia, RDT)
nausea, vomiting) of malaria who receives anti-malarial treatment AND with laboratory • Confirmed malaria death: death of a patient classified as confirmed severe
confirmation of diagnosis. malaria.
• Confirmed severe malaria case: A person who requires hospitalization for symptoms and • Malaria treatment failure: A patient with uncomplicated malaria without any clear
signs of severe malaria (coma, generalized convulsions, hyperparasitemia, normocytic symptoms suggesting another concomitant disease who has taken a correct
anemia, disturbances in fluid, electrolyte, and acid-base balance, renal failure, hypoglycemia, dosage of anti-malarial treatment, and who presents with clinical deterioration or
hyperpyrexia, hemoglobinuria, circulatory collapse/shock, spontaneous bleeding, recurrence of symptoms within 14 days of the start of treatment, in combination
with parasitemia (asexual forms).
Non-neonatal Tetanus (ICD 10 Code: A35)
Date of
Patient No. Patient’s Full Name Age Sex Occupation Complete Address
Birth
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
Age: Indicate
D - days
Response
Indicate First name, Middle name, Last M - months Indicate
Codes / mm/dd/yy Specify Street/Purok/Subdivision, House #, Barangay, Municipality/City, Province
name Yr. - years occupation
Instructions
Sex:F - Female
M - Male
Case Definition/classification:
Confirmed Case:
Acute onset of hypertonia and/or painful muscular contractions (usually muscles of the neck and jaw) and generalized muscle spasms without other apparent medical cause as reported by a
health care professional.
Philippine Integrated Disease Case Report Form Surveillance and Response Non-neonatal Tetanus (ICD 10 Code: A35)
Received Received
Date Date of tetanus tetanus
Admitted With recent Out-
Patient’s Full Name Admitted/seen/ Onset of Wound site Wound type toxoid antitoxin Skin lesions
? wound? come
consulted Illness vaccination or TIG?
?
___/___/___ ___/___/___
___/___/___ ___/___/___
___/___/___ ___/___/___
___/___/___ ___/___/___
___/___/___ ___/___/___
___/___/___ ___/___/___
___/___/___ ___/___/___
___/___/___ ___/___/___
Head & Neck • Abrasion Y - Yes (specify)
Y = Yes Trunk • Animal bite N - No
N = No Upper • Avulsion U - Unknown
U = extremity • Burn NOTE: Skin
Unknown Lower extremity • Open fracture lesions for the
A - Alive
NOTE: Unknown • Crash past 3 months,
Y - Yes D - Died
Recent • Dental (caries/ Y - Yes which may
Y - Yes N- extraction) N - No (specify
Response Codes / Instructions mm/dd/yy mm/dd/yy wound N - No include : abscess,
No • Fireworks U - date)
refers to U - Unknown ulcer, blister,
• Insect bite Unknown U-
past 3 gangrene,
• Laceration Unknown
months cellulitis, etc.
whether • Puncture
healed or • Surgery
not • Tissue necrosis
• Others, specify

Surveillance and Response Pertussis (ICD 10 Code: A37)
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
Age: Indicate
D - days
Response
M - months
Yr. - years
Instructions
Sex: F - Female
M - Male
Case Definition/ classification: Laboratory-confirmed case:

Clinically-confirmed case: • A case of acute cough illness of any duration with a positive culture for B. pertussis;
• A case that meets the clinical case definition but is not laboratory confirmed. OR
Probable case: • A case that meets the clinical case definition and is confirmed by PCR; OR A case
• Meets the clinical case definition, is not laboratory confirmed, and is not epidemiologically that meets the clinical definition and is epidemiologically linked directly to a case
link to a laboratory-confirmed case. confirmed by either culture or PCR. ed Laboratory Confirmation:
• Isolation of Bordetella pertussis, or detection of genomic sequences by polymerase
chain reaction (PCR).
Philippine Integrated Disease Case Report Form Surveillance and Response Pertussis (ICD 10 Code: A37)
No. of DPT
Date Admitted/ Date of onset Date of last Case
Patient’s Full Name Admitted?
seen/consulted
doses Outcome
of Illness DPT Classification
received?
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___
___/___/___ ___/___/___ ___/___/___

0
A - Alive
1
Y - Yes S - Suspect C D - Died (specify
Response Codes / Instructions mm/dd/yy mm/dd/yy 2 mm/dd/yy
N- No - Confirmed date)
3
U - Unknown
Unknown

Typhoid and Paratyphoid Fever (ICD 10 Code: A01)
____/____/____
____/____/____
____/____/____
____/____/____
____/____/____
____/____/____
____/____/____
____/____/____
Age: Indicate
D - days
Response
M - months
Yr. - years
Instructions
Sex: F - Female
M - Male
• Suspected case: A person with an illness characterized by insidious onset of
sustained  Confirmed case: A suspected or probable case that is laboratory confirmed.
fever with headache, malaise, anorexia, relative bradycardia, constipation or diarrhea, and non-productive cough.
Laboratory Confirmation:
• Isolation of Salmonella enterica from blood, stool, or other clinical specimen 
Probable case: A suspected case that is epidemiologically linked to a confirmed case in an outbreak or, a suspected case positive for Typhidot test.

Case Report Form
Hand, Foot and Mouth Disease and Severe Enterovirus Disease
Suspected case of HFMD: Any individual, regardless of age, who develop acute febrile illness with papulovesicular or
maculopapular rash on palms and soles, with or without vesicular lesion/ulcers in the mouth.
Probable case of HFMD: A suspected case that has not been confirmed by a laboratory, but is geographically and
temporally related to a laboratory-confirmed case.
Confirmed case of HFMD: A suspected case with positive laboratory result for Human Enteroviruses that cause HFMD.
Suspected case of Severe Enteroviral Disease: Any child less than ten (10) years of age: with fever plus any severe signs
and symptoms referable to central nervous system involvement, autonomic nervous system dysregulation or cardiopulmonary
failure;
OR a suspect or probable HFMD case with complications
OR who died < 48hours after presenting with fever and CNS involvement;
Confirmed case of Severe Enteroviral Disease: A suspected Severe Enteroviral Disease that has positive laboratory
results for Enteroviruses
COMPLICATIONS TED WITH HFMD AND SEVERE ENTEROVIRUSDISEASE:

ASSOCIA
Aseptic Meningitis Febrile illness with headache, vomiting and meningism associated with of more
that 5-10 white cells per cubic millimeter in cerebrospinal (CSF) fluid, and nega-
tive results on CSF bacterial culture.
Brainstem encephalitis Myodonus, ataxia, nystagmus, oculomotor palsies, and bulberpalsy in various
combinations, with or without MRI. In resource –limited settings, the diagnosis of
brainstem encephalitis can be made in children with frequent myoclonic jerks

and CSF pleocytosis.
Encephalitis Impaired consciousness, including lethargy, drowsiness or coma, or seizures or
myoclonus.
Encephalomyelitis Acute onset of hyporeflexic flaccid muscle weakness with myoclonus, ataxia,
nystagmus, oculomotor palsies and bulbar palsy in various combinations.
Acute Flaccid Paralysis Acute onset of flaccid muscle weakness and lack of reflexes.
Autonomic Nervous System (ANS) Presence of cold sweating , mottled skin, tachycardia, tachypnea, and
dysregulation hypertension
Pulmonary age Respiratory distress with tachycardia, tachypnea, rales, and pink frothy
oedema/haemorrh secretion that develops after ANS dysregulation, together with a chest
radiograph that shows bilateral pulmonary infiltrates without cardiomegaly.
Cardiorespiratory failure Cardiorespiratory failure is defined by the presence of tachycardia, repiratory

distress, pulmonary oedema, poor peripheral perfusion requiring inotropes,
pulmonary congestion on chest radiography and reduced cardiac contractility on
echocardiography.

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Philippine Integrated Disease Republic Act 3573 (Law of Reporting of Communicable Surveillance and

Response Diseases), requires all individuals and health facilities to

Weekly Notifiable Disease Report

Category I (Immediately Notifiable) Category II (Weekly Notifiable)

_____ Acute Flaccid Paralysis0 _____ Acute Bloody Diarrhea0

Outcome:  Alive Patient sustained disability?  Yes No Unknown

Complete Address: MM DD YY Age:

II. CLINICAL Admitted? Date Admitted/ MM DD YY Date Onset of MM DD YY

INFORMATION: Yes No Unknown Seen/Consult Illness

 Fever  Stomach pain  Neck pain

 Y N U Is the patient’s occupation associated with animals or agriculture?

IV. CLINICAL FORMS, CLASSIFICATION AND OUTCOME:

Philippine Integrated Disease Surveillance and Response

Fever:  Y  N Arthralgia/arthritis:  Y N Are there any complications?

Serum ___ /___ /___ ___ /___ /___

Dried Blood Spot ___ /___ /___ ___ /___ /___

OraCol? ___ /___ /___ ___ /___ /___

VI. FINAL CLASSIFICATION VII. SOURCE OF INFECTION

VIII. OUTCOME:  Alive  Died  Unknown Date died:___/___/___

Philippine Integrated DiseaseSurveillance and Response Case Investigation Form

Complete Address: MM DD YY Age:

Name of School: Address of School:

II. CLINICAL Admitted? Date Admitted/ MM DD YY Date Onset MM DD YY

INFORMATION: Yes No Unknown Seen/Consult of Illness

Fever Seizure Malaise

IV. LABORATORY TESTS:

Case Investigation Form

What is the address of the suspected or confirmed meningococcal case?

Complete Address: MM DD YY Age in days:

II. CLINICAL DATA:

III. MOTHER’S INFORMATION:

IV. DELIVERY PRACTICES:

V. CLASSIFICATION AND OUTCOME:

Case Investigation Form

Complete Address: MM DD YY Age:

Patient Admitted?  Yes  No  Unknown Date Admitted/ MM DD YY Date Onset of MM DD YY

II. EXPOSURE HISTORY:

III. CLASSIFICATION AND OUTCOME:

Complete Address:  Male Date of MM DD YY Age:  Days

II. EXPOSURE HISTORY:

III. CLASSIFICATION AND OUTCOME:

CASE DEFINITION/CLASSIFICATION: • Probable Case: Not applicable

Complete Address: MM DD YY Age:

Patient Admitted?  Yes  No  Date Admitted/ MM DD YY Date Onset of MM DD YY

II. EXPOSURE HISTORY:

III. CLASSIFICATION AND OUTCOME:

Complete Address: MM DD YY Age:  Days

II. EXPOSURE HISTORY:

III. CLASSIFICATION AND OUTCOME:

 Suspected Case  Alive

___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___

___/___/___ ___/___/___ ___/___/___

_ Acute Flaccid Paralysis0 _ Acute Bloody Diarrhea0

Serum _ /_ /_ _ /_ /_

Dried Blood Spot _ /_ /_ _ /_ /_

OraCol? _ /_ /_ _ /_ /_

VIII. OUTCOME:  Alive  Died  Unknown Date died:_/_/___

_/_/_ _/_/_ _/_/___

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