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 Lampiran 1. Formulir Investigasi Kasus Congenital Rubella
Syndrome

IDENTITAS PELAPOR
Nama Rumah Sakit : ................................................................................................ Alamat Rumah
Sakit : ................................................................................................ :
Kab/Kota..................................................Provinsi...................
Tanggal Laporan Diterima : ...................................................................... Tanggal
Investigasi : ......................................................................

IDENTITAS KASUS
Nomor EPID : ...................................................................... (isikan setelah berhasil input di
web based PD3I)
Nomor Rekam Medis : ...................................................................... Nama bayi :
…………………….Jenis Kelamin: Laki-laki  Perempuan  Tanggal lahir : ..............................(umur
dalam bulan: ….........bulan) Alamat
Kasus : ................................................................................................ :
Kec. .........................................................Kab/Kota.................
: Provinsi..........................................................
Tempat kasus dilahirkan : ................................................................................................. Nama
Ibu : ...................................................................... Nomor telepon orang
tua : ...................................................................... Umur kehamilan saat bayi
dilahirkan : .................................................................. minggu Berat badan bayi saat
lahir : ...................................................................... gram
TANDA DAN GEJALA KLINIS
Nama dokter pemeriksa:
1. Anak : ................................................................................................ No. HP: ........... 2.
Mata : ................................................................................................ No. HP: ........... 3.
THT : ................................................................................................ No. HP: ........... 4.
Kardiologi : …………………………………………………..No. HP:
…………………………………
Keadaan bayi saat ini : Hidup  Meninggal 
Bila Meninggal, jelaskan penyebab kematian :
..................................................................................................
Tanggal periksa pertama kali :
Tanggal ditetapkan sebagai suspek CRS : ..........................................................
Group A (lengkapi semua tanda dan gejala yang ada)
Congenital heart disease: Ya  Tidak  Tidak tahu  Congenital cataracts: Ya  Tidak 
Tidak diperiksa  Congenital glaucoma: Ya  Tidak  Tidak diperiksa  Pigmentary
retinopathy: Ya  Tidak  Tidak diperiksa  Hearing impairment: Ya  Tidak  Tidak tahu 
Group B (lengkapi semua tanda dan gejala yang ada)
Purpura: Ya  Tidak  Tidak tahu  Microcephaly: Ya  Tidak  Tidak tahu 
Meningoencephalitis: Ya  Tidak  Tidak tahu  Ikterik 24 jam post partum: Ya  Tidak
 Tidak tahu  Splenomegaly: Ya  Tidak  Tidak tahu  Developmental delay: Ya 
Tidak  Tidak tahu  Radiolucent bone disease: Ya  Tidak  Tidak tahu  Other
abnormalities*: Ya  Tidak 
*Bila Ada, jelaskan:
...................................................................................................................................

RIWAYAT KEHAMILAN IBU

Kehamilan ke berapa : ............................................ Umur Ibu saat melahirkan tahun Hari Pertama
Haid Terakhir (HPHT) pada kasus ini.................... : ................................................. Apakah selama
kehamilan ini Ibu pernah mengalami:

• Conjunctivities : Ya  Tidak  Tidak tahu  Bila ya, trimester kehamilan I  II  III 

Pilek : Ya  Tidak  Tidak tahu  Bila ya, trimester kehamilan I  II  III 

Batuk : Ya  Tidak  Tidak tahu  Bila ya, trimester kehamilan I  II  III 
Ruam makulopapular : Ya  Tidak  Tidak tahu  Bila ya, trimester kehamilan I  II 
III 
Limfadenitis : Ya  Tidak  Tidak tahu  Bila ya, trimester kehamilan I  II  III 
Demam : Ya  Tidak  Tidak tahu  Bila ya, trimester kehamilan I  II  III 
Arthralgia/ Arthritis : Ya  Tidak  Tidak tahu  Bila ya, trimester kehamilan I  II  III 
Komplikasi lain : Ya  Tidak  Tidak tahu  Bila ya, trimester kehamilan I  II  III 

• Apakah sebelum kehamilan ini Ibu mendapat imunisasi rubella?

Ya  Tidak  Tidak tahu  Bila ya, tanggal diberikan ___ /___ /___ • Apakah selama

kehamilan ini Ibu pernah didiagnosa rubella dengan konfirmasi lab? Ya  Tidak  Tidak tahu 

Bila ya, tanggal kejadian ___ /___ /___ • Apakah selama kehamilan terakhir ini Ibu pernah

terpapar atau berkontak dengan orang yang menderita ruam makulopapular?

Ya  Tidak  Tidak tahu  Bila ya, umur kehamilan saat itu: ...…….minggu. Jelaskan
dimana :
..................................................................................................

• Apakah ibu bepergian selama kehamilan terakhir ini?

Ya  Tidak  Tidak tahu 

Bila ya, tanggal kejadian___/___/___ Umur kehamilan saat itu: ...minggu. Jelaskan
kemana :
.........................................................................................................
PEMERIKSAAN LABORATORIUM
Apakah spesimen diambil : Ya  Tidak  Tidak tahu  Jenis pemeriksaan : IgM  IgG 
PCR 

Jenis spesimen Tanggal Tanggal kirim ke Lab Tanggal tiba di Lab

ambil (Lab RS / Lab Nasional)*

Serum 1

Serum 2 (Bila diulangi)

Apus tenggorok

Urine

Lensa mata

*) Coret yang tidak perlu

Hasil Pemeriksaan Laboratorium:

Jenis pemeriksaan IgM IgG PCR Genotyping Jenis Tanggal
Virus Hasil Lab

Serum 1

Serum 2 (Bila
diulangi)

Apus tenggorok

Urine

Lensa mata

KLASIFIKASI FINAL
CRS pasti (konfirmasi lab)  CRS klinis  Bukan CRS / discarded  Bukan Suspek CRS 
Tanggal: ____/____/____
Mengetahui,
Investigator Ketua Tim CRS

__________________________________ ________________________________
Nama :........................................................... Nama :
Nomor HP : .......................................................... Nomor HP :
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