Version 2022

Epidemic-prone Disease
Case Surveillance Case Investigation Form
Rotavirus Surveillance
I. INFORMATION ABOUT THE DISEASE REPORTING UNIT (DRU)
Name of DRU: ACEMC PALAWAN Contact Number of DRU: Type: RHU CHO Gov’t Hospital
Region of DRU: IV-B Private Hospital Clinic
Province of DRU:
09176322011  Airport/Seaport Others:______
PALAWAN Type of site: Sentinel Non-Sentinel
II.PATIENT EPIID No: Patient Case Patient’s Last Name: First Name: Middle Sex: Male Date of Birth: Age: ________
INFORMATION Number: Name: Female Days  Months
___/___/____
mm dd yyyy Years

Complete Current Address: (Specify House No./ Street/ Purok/ Subdivision/ Brgy/ Municipality/ City/Province, Region) Is patient enrolled in 4 P’s
Is the patient is member
(National Household
of Indigenous People(IP):
Targeting System)?
Y N
Y N
Complete Permanent Address: (Specify House No./ Street/ Purok/ Subdivision/ Brgy/ Municipality/ City/Province, Region) If Yes, Specify
_________

III.CLINICAL DATA (Put a check [ √ ] in the appropriate box) IV.EPIDEMIOLOGIC V. IMMUNIZATION HISTORY VI. DETAILS OF INVESTIGATOR/
REPORTING
Date of Onset of Diarrhea: ___/___/_____(mm/dd/yyyy) Are there two or Received Rotavirus Vaccine? Name of Investigator:
Was Patient admitted at the ward for diarrhea?  Y  N more Y  N
If yes, date of admission: ___/___/_____(mm/dd/yyyy) diarrhea cases? _________________________________
If Yes, total doses received:____ Position/Designation:
Did patient receive IV rehydration therapy while at the ER?  Y  N
 Yes
Did patient have previous hospitalization due to diarrhea?  Y  N Date first dose received: _________________________________
If yes, date of hospitalization___/___/_____(mm/dd/yyyy) If Yes, where:
____/____/_____ Contact Numbers:
 Community mm dd yyyy
Vomiting:  Y  N
 School _________________________________
If yes, date of onset of vomiting: ___/___/____(mm/dd/yyyy) Date last dose received:
____/____/_____ Date of Investigation: ____/___/____
Degree of Dehydration: No dehydration  Some dehydration Severe dehydration  Household mm dd yyyy mm dd yyyy
 No Date of Report: ____/___/____
Fever:  Y N
 Unknown mm dd yyyy
ADMITTING DIAGNOSIS:____________________________________________
FINAL DIAGNOSIS:_______________________________________________

VII. LABORATORY DATA VIII. CLASSIFICATION AND OUTCOME

STOOL SPECIMEN SPECIMEN CONDITION AND ADEQUACY ELISA RESULT PCR RESULT Classification: Suspected  Y  N
(To be filled out by RITM) (To be filled out by RITM) (To be filled out by RITM)
Confirmed  Y  N
Stool Collected?  Y  N Date received by RITM:____/___/____ NEG POS Genotype:
If YES, date taken: mm dd yyyy _________________ Outcome:
Condition:  Frozen  Thawed but cold  Warm Equivocal  Alive
____/___/____ Date of result
mm dd yyyy No. of ice packs: _________ Date of result: Date of discharge: ___/___/____
____/____/____ mm dd yyyy
Date sent to RITM: Quantity of stool: mm dd yyyy
____/____/____
Sufficient Sufficient for ELISA but no remaining sample mm dd yyyy  Died
____/___/____
mm dd yyyy Insufficient Date of Death: ___/___/____
mm dd yyyy
CASE DEFINITION AND CLASSIFICATION:
Suspected Case: Acute (< 14 days) watery diarrhea, defined as three or more loose or watery s tools in a 24-hour period in a child < 5 years of age who is admitted for treatment of diarrhea to a hospital ward or
emergency unit at a participating surveillance facility. Children with bloody diarrhea and nosocomial infections are excluded.
Confirmed Case: A suspected case in whose stool the presence of rotavirus is demonstrated by means of an antigen-based enzyme immunoassay (EIA) or any 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