Communicable Disease Notifying Form Page 2
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2CCHDC-V5-Feb-2012
Communicable Disease Notifying Form
Health Protection Agency
Male’, Republic of Maldives
*Reporting Institution
, address and contact numbers (
:
for tracing further information if required)
* Case based Notifiable Diseases (
)
place appropriately
Scrub Typhus
Acute Flaccid Paralysis
Measles
Encephalitis ______________
Tetanus/
Chickenpox / Zoster
Neonatal
Meningitis
Filariasis
Typhoid/
Chikungunya
Paratyphoid
Hand, Foot & Mouth Disease
Mumps
Whooping cough
Hepatitis: Type A/B/C/D/E
Cholera
Plague
Leprosy
Yellow Fever
Dengue fever/ DHF/ DSS
Pneumonia
Other emerging
Leptospirosis
Diphtheria
Rubella
disease_______________
Malaria
Dysentery
Case Details (Mandatory fields are marked with (*). Please make sure to complete them.
(
*Case classification:
Suspect
Probable
Confirmed
as per surveillance case definition)
*Patient Name:
*Age: ____ /____
*Sex:
Registration number
M
F
(Y Y / MM)
Permanent Address:
Atoll:
Island:
If Non‐national: Country of origin
(For identification)
*Residential Address:
*Atoll:
*Island:
Contact Phone no.:
(At the time of contracting illness)
*Date of onset of illness: ____/____/______
*Date of Consultation /Admission: ____/____/_____
DD / MM / YYYY
DD / MM / YYYY
*Patient category
Clinical details
(include risk factors, mode of transmission, etc.)
Out‐patient
In‐patient: Ward __________ Bed _____
ICU ____________ Bed _____
Recent travel history
Date of arrival in Maldives: ____/____/________
if relevant (include countries visited)
DD / MM / YYYY
Condition of patient
Stable
Sick
Critically ill
Laboratory Confirmation:
:
Confirmed: Test specifics______________________
*Case outcome:
If Requested, Date: ____/___/______
DD / MM / YYYY
Death
On treatment
Referred to higher centre
Not Requested
Recovered with disability
Recovered fully
*
Re‐notification
(required for changes in diagnosis (e.g. Dengue Fever to DHF), case confirmation or outcome (e.g. death).
Notifier details
Data entry use
Name:_________________ Designation: ____________
Date received: ___/___/___; Date of entry: ___/___/___
Signature: ______________ Date: ____/____/_____
Checked and entered by: ___________________
For further information or inquiries, please contact:
Health Protection Agency
Roshanee Building, Sosun Magu, Male’.
Telephone: +960 3014 496, Hotline: +960 3014 333
Fax: +960 3014 484
Forms and case definition booklet are available on
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