Version 2022

Epidemic-prone Disease Case Report Form

Influenza-like Illness (ICD 10 Code: J11)
Case Surveillance

Region: NCR
____________________________ METRO MANILA
Province: ___________________________ QUEZON CITY
Municipality/City: ________________________________________
Name of DRU: ABC RURAL UNIT
_________________________________________________________________ Type: ⃞RHU ⃞CHO/MHO/PHO ⃞Gov’t Hospital ⃞Private Hospital
Address: AGHAN ROAD, QUEZON CITY
_________________________________________________________________ ⃞Clinic ⃞Gov’t Laboratory ⃞Private Laboratory ⃞Airport/Seaport
CHRISTINE P. AÑO
Name of Interviewer: _____________________________________________________________ Type of site: ⃞Sentinel ⃞Non-sentinel

Re-
Hx of
ceived
travel Date
If yes, Date Anti Date Date of
Patient Patient’s Civil Complete Current Complete Permanent abroad onset Laboratory Classifica- Out-
Age Sex Date of Birth Specify IP Admitted? admitted/ influ- of last specimen Result
No. Full Name Status Address Address for the of Done tion come
where? seen/ enza vaccination collection
last illness
consulted vac-
21days?
cine

12345 DISTRICT II 12345 DISTRICT II

ABC 123 STA. CRUZ ST. STA. CRUZ ST. HONG KONG N
SANTOS, ROSA B. 30Y F S BARANGAY X, Y N ISOLATION POSITIVE
A
12 22 1990
BARANGAY X,
PACO, MANILA PACO, MANILA PCR INFLUENZA
A (H3)
C
___/___/___ 03 12 2021 ___/___/___
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S-
Age: Indicate Single
D - days M- Isolation
Specify House # Specify House # Y-Yes A - Alive
Indicate M - months Married Y-Yes PCR S - Suspect
Response Street/Purok/ Street/Purok/ N-No Y-Yes
Last name, Yr - years Sep- N-No Place of mm/dd/ Y-Yes mm/dd/ mm/dd/ Specify D - Died
Codes / mm/dd/yyyy Subdivision, Baran- Subdivision, Baran- (Please N-No mm/dd/yyyy Serology; C - Confirmed
First name, Sepa- Travel yyyy N-No yyyy yyyy organism (specify
Instructions rated gay, Municipality/City, gay, Municipality/City, specify viral culture
Middle name Sex: date died)
W- Province, Region Province, Region tribe)
F - Female
Wid-
M - Male owed

Case Definition and Classification: Laboratory Confirmation:

• Suspected case: A person with acute respiratory infection, with measured fever of ≥38°C and cough with onset within the last 10 days. • Virus isolation or Polymerase Chain Reaction (PCR) of swab or aspirate from the suspected Individual or direct detection of influen-
• Confirmed case: a suspect ILI case who has laboratory confirmation of influenza virus infection, using one of the following criteria: za viral antigen or 4-fold rise in antibody titer between early and late serum.
- virus isolation - molecular diagnostic test

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