Form Cdc 54.1 - Malaria Case Surveillance Report Page 2
ADVERTISEMENT
1
2Physicians and other health care providers with questions about diagnosis and treatment of malaria cases
can call CDC’s Malaria Hotline:
- Monday – Friday, 9:00 am to 5 pm, EST: call 770-488-7788 or 855-856-4713 (Fax: 404-718-4815)
- Off-hours, weekends, and federal holidays: call 770-488-7100 and ask to have the malaria clinician on call paged.
Information on malaria risk, prevention, and treatment is available at:
CDC’s Malaria Web site
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Part II (to be complete 4 weeks after treatment)
Please list all prescription and over the counter medicines the patient had taken during the 2 weeks before starting their treatment for malaria.
Please list all prescription and over the counter medicines the patient had taken during the 4 weeks after starting their treatment for malaria.
Was the medicine for malaria treatment taken as prescribed?
No, doses missed
Yes, no doses missed
Unknown
Did all signs or symptoms of malaria resolve without any additional
If yes, did the patient experience a recurrence of signs or symptoms of
malaria treatment within 7 days after treatment start?
malaria during the 4 weeks after starting malaria treatment?
Yes
No
Unknown
Yes
No
Unknown
Did the patient experience any adverse events within 4 weeks after receiving the malaria treatment?
Yes
No
Unknown
(If Yes): Event description
Relationship
Time to
Fatal?
Life-
Other
to treatment
Onset since
Threatening? Seriousness?**
suspected*
treatment start
1 ________________________________________
__________
2 ________________________________________
__________
3 ________________________________________
__________
4 ________________________________________
__________
5 ________________________________________
__________
* Suspected means that a causal relationship between the treatment and an adverse event is at least a reasonable possibility, i.e., the relationship cannot be ruled out.
** A serious adverse event is defined as an event which is fatal or life-threatening, results in persistent or significant disability/incapacity, constitutes a congenital
anomaly/birth defect, is medically significant (i.e., jeopardizes the patient or may require medical or surgical intervention), or requires inpatient hospitalization or
prolongation of existing hospitalization.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Oic-wc-1 - Employees' And Physicians' Report Of Occupational Injury Or Disease - West Virginia Workers' Compensation
Legal
Form St-100.1 - Quarterly Schedule W - Report Of Purchases Eligible For Credit By A Qualified Empire Zone Enterprise (qeze) - 2015
Financial
Related Categories
Parent category: Legal