Integrated Health Information Platform

Integrated Disease Surveillance Programme

Ministry of Health and Family Welfare,Government of India
S Form Report- Unsubmitted Document Number : 8-112-645-0-8588232549-19022024-S-2

Facility Information
1.1 Facility Name :Kalla Khedi 1.9 Contact Number :7229885546 1.16 State Surveillance Officer :PRAVEEN ASWAL

1.2 Facility Type :Health Sub Centre 1.10 Village : 1.17 Contact Number :+91-9002162770

1.2a PHC :Kotharia 1.11 Sub District :Nathdwara 1.18 District Surveillance :Dr. Jinesh kumar Saine

1.3 Facility NIN :8588232549 1.12 District :RAJSAMAND 1.19 Contact Number :+91-7062434445

1.4 Personnel in Charge :Suman Devi 1.13 State :Rajasthan 1.20 Sub Distict Surveillance :

1.5 Contact Number :7229885546 1.21 Contact Number :

1.6 Data Entry Personnel :Vishal Paliwal 1.22 Medical Officer PHC :Not Available
1.23 Contact Number :Not Available

S Form (Suspected Cases Form) Village Name:

Number of cases Number of Death cases *
( Please enter linelisting of death
Male Female
Grand cases in next section)
<= 5 Total
<= 5 yr > 5 Yr Total > 5 Yr Total
Yr Male Female Total Death

2.1.1 Only Fever >= 7 days

2.1.2 Only Fever < 7 days

2.1.3 Fever with Rash

2.1.4 Fever with Bleeding

2.1.5 Fever with Altered sensorium

2.2.1 Cough <= 2 weeks with fever

2.2.2 Cough <= 2 weeks without fever

2.2.3 Cough > 2 weeks with fever

2.2.4 Cough > 2 weeks without fever

Report Generated on 19/02/2024 Page 1 of 3

 S Form Report- Unsubmitted Document Number : 8-112-645-0-8588232549-19022024-S-2

2.3.1 Loose watery stools with blood < 2 weeks

2.3.2 Loose watery stools without blood < 2 weeks

2.4.1 Jaundice of < 4 weeks

2.5.1 Acute Flaccid Paralysis

2.6.1 Malaria Vivax RDT

2.6.2 Malaria Falciparum RDT

2.6.3 Malaria Mixed RDT

2.7.1 Animal Bite - Snake Bite

2.7.2 Animal Bite - Dog Bite

2.7.4 Animal Bite - Others

2.7.5 Leptospirosis RDT

2.14.1 Others

Report Generated on 19/02/2024 Page 2 of 3

 S Form Report- Unsubmitted Document Number : 8-112-645-0-8588232549-19022024-S-2

List of Reported Deaths

2.7. 2.8. ID 2.12. 2.13. Sub 2.14. 3.1. Probable 3.3.

SLno 2.2. Person Name 2.5. Age 2.11. State 2.15. Address 3.2. Date of Death
Gender Type/Id No District District Village Cause Of Death Remarks

End Of Report

Report Generated on 19/02/2024 Page 3 of 3