Weekly Aggregate Reporting form for Health Facilities, WoHO, ZHD and RHB

Health Facility Name and Type DillFana Primary Hospital Woreda Arbaminch Towin
Zone Gamo Region SNNP
Start of week from Monday 15/5/2015 to Sunday 21/5/2015E.C
WHO EPI-Week Monday to Sanday
(day)(month)(Year in Gregorian Calendar)(day) (month)

1. Record below the total number of cases and deaths for each disease/condition for the current week
Out - Patient In - Patient
Indicator
Cases Cases Deaths
Total malaria cases 281 1 0
Total malaria suspected fever cases tested by RDT or Microscopy 1748 0
P. falciparum 203 0 0
Number of cases positive for malaria parasites (either by RDT or Microscopy)
P. vivax 78 0 0
Meningitis 0 0 0
Dysentery 5 0 0
Scabies 0 0 0
Relapsing fever 0 0 0
Severe Acute Malnutrition /MUAC < 11.5cm and/or Bilateral Edema in under 5 years children (new cases only) 2 0 0
Moderate Acute Malnutrition: U5C 0 0
Moderate Acute Malnutrition: PLW 0 0
Diarrhea with dehydration in children less than 5 years of age 3 0 0
Acute jaundice syndrome within 14 days of illness 1 0 0
Severe pneumonia in children under 5 years age 2 0 0
Diabetic Mellitus new cases 3 0 0
HIV new cases 2 0 0
Tuberculosis new cases 0 0 0
Hypertension new cases 2 0 0
RDT = Rapid Diagnostic Test; MUAC = mid upper arm circumference; PLW = Pregnant and lactating woman ; U5C = Under 5 years child
 2. Summary for Immediately Notifiable Disease / Conditions: (Total cases and deaths reported on case-based forms or line lists during the reporting week)
Out - Patient In - Patient
Indicator
Cases Cases Deaths
AFP/Polio 0 0 0
Anthrax 0 0 0
Cholera 0 0 0
Dracunculiasis (Guinea worm) 0 0
Chikungunya 0 0 0
Adverse events following immunization (AEFI) 0 0 0
Measles 0 0 0
Neonatal Tetanus 0 0 0
Human influenza caused by new subtype 0 0 0
Suspected rabies exposure 0 0 0
(Human) Rabies 0 0 0
Dengue fever 0 0 0
SARS 0 0 0
Small pox 0 0 0
Viral hemorrhagic fever 0 0 0
Yellow fever 0 0 0
COVID-19 7 0 0
Monkeypox virus 0 0 0
Rift Valley Fever 0 0 0
Brucellosis 0 0 0
Maternal death 0
Perinatal death 0
Obstetric fistula 0 0 0
Other (specify)_____________ 0 0 0
RDT = Rapid Diagnostic Test; MUAC = mid upper arm circumference; PLW = Pregnant and lactating woman ; U5C = Under 5 years child
 3. Report timeliness and completeness (to be filled only by Woreda Health Office and Zone/Regional Health Bureaus/regional public health
institutes)
Government NGO
Private Health
Indicator Health Health Hospital (Primary/ Secondary/Tertiary) Health Others
Facility
Post Center Facility
Number of sites that are supposed to report weekly - - 1 - - -
Number of sites that reported on time - - 1 - - -
4. Any events notification from community members
Indicator Number
Total number of notifications from community
Total number of notifications fulfilling case definition utilized by
HEWs
Total number of notifications done within 30 minutes of
detection

Look at the trends, abnormal increase in cases, deaths, or case fatality ratios? Improving trends? Actions taken and Recommendations:

Date sent by HF/Woreda/Zone/Region: 21/5/2015E.C Date received at Woreda/Zone/Region: _________

Sent by: Afework Milkiyas Received by: _________________