Form Cdc 54.1 - Malaria Case Surveillance Report printable pdf download

MALARIA CASE SURVEILLANCE REPORT

Department of Health and Human Services, Centers for Disease Control and Prevention

Division of Parasitic Diseases (MS F-22), 4770 Buford Highway, N.E. Atlanta, Georgia 30341

Part I

State Case No: .......................

CSID No................................

Case No: .........................

Patient name (last, first):

Age: _______

Sex:

yrs. mos. wks. days (circle units)

Date of Birth: ____/ ____/ ________

Male

Date of symptom onset of this attack (mm/dd/yyyy): ____/ ____/ _____

Is patient pregnant?

Yes

Female

Height: ____

_____

Weight:____

Unknown

ft. and

in.

lbs.

Physician name (last, first):

Ethnicity:

Race (select one or more):

Hispanic or Latino

American Indian/Alaska Native

Not Hispanic or

Native Hawaiian/Other Pacific Islander

Telephone Number: (

) _________ – ___________

Latino

Black or African American

Asian

White

Unknown

Positive lab test result (check all that apply):

State/territory reporting this case: ___________________

Smear

PCR

RDT

No test done/unknown

County: ___________________

Species (check all that apply):

Patient admitted to hospital:

Yes

Unknown

Vivax

Falciparum

Malariae

Ovale

Not Determined

Hospital: _______________________________________



Other species (specify) __________________

Date: ____/ ____/ ________ Hospital record No.: ________

Parasitemia (%): _______________________

Laboratory name:

Specimens being sent to CDC?

Yes

Unknown

Telephone Number: (

) _________ – ___________

If yes:

Smears

Whole Blood

Other: _______________

Has the patient traveled or lived outside the U.S. during the past 2 years?

Yes

If yes, specify:

Country:

1. ________________

2. _________________

3. ___________________

Date returned/ arrived in U.S. (mm/dd/yyyy):

____/ ____/ ______

____/ ____/ ________

Duration in country

_________________

__________________

___________________

yrs. mos. wks. days (circle units)

Did patient reside in U.S. prior to most recent travel?

Principal reason for travel from/ to U.S. for most recent trip:

Yes

Tourism

Visiting friends/relatives

Student/teacher

Military

Airline/ship crew

Other: ____________

No, (specify country): _____________________



Business

Missionary or dependent

Unknown

Peace Corps

Refugee/immigrant

Was malaria chemoprophylaxis taken?

Yes

Unknown



If yes, which drugs were taken?

Chloroquine

Mefloquine

Doxycycline

Primaquine

Atovaquone/proguanil

Other: ______________________________

Unknown

History of malaria in last 12 months

Was chemoprophylaxis

If doses were missed, what was the reason?

(prior to this report)

Yes

Unknown

taken as prescribed?

Forgot



Didn’t think needed

Date of previous illness: ____/ ____/ ________

Yes, missed no doses

Had a side effect (specify): ________________



If yes, species (check all that apply):

Was advised by others to stop

No, missed doses

Prematurely stopped taking once home

Vivax

Falciparum

Malariae

Ovale



Other (specify): _________________________

Unknown



Not Determined

Other (specify) _____________

Unknown

Blood transfusion/organ transplant within last 12 months:

Yes

Unknown

If yes, date: ____/ ____/ ________

Clinical

Cerebral malaria

ARDS

None

Was illness fatal:

Yes

Unknown

Complications:

Renal failure

Severe anemia(Hb<7)

Other : ____________ If yes, date of death : _____/____/_______

Therapy for this attack (check all that apply):

Chloroquine

Tetracycline

Doxycycline

Mefloquine

Exchange transfusion

Artesunate

Artemether/lumefantrine

Unknown

____________________________

Primaquine

Quinine

Quinidine

Clindamycin

Atovaquone/proguanil

Other (specify):

Person submitting report:

Telephone No. :

Affiliation:

Date Submitted: __________/__________/_____________

For CDC Use Only.

Classification

Imported

Induced

Introduced

Congenital

Cryptic

Public reporting burden of this collection of information is estimated to average 15 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to, a collection

of information unless it displays a currently valid OMB control number. Please send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions

for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Rd., NE (MS D-24); Atlanta, GA 30333; ATTN: PRA (0920-0009).

OMB 0920-0009

CDC 54.1 11/2011 (Front)

If sending specimens, please forward blood smears (thick and thin) with this report.