Immediate/Case-based Surveillance Reporting Form IDS

REPORTING HEALTH FACILITY

IDENTIFICATION NUMBER

Acute Flaccid Buruli Cholera Diphteria Dracunculiasis Dengue Influenza due to new subtype e
Paralysis/Poliomyel ulcer (Guinea Worm) H5N1
itis (AFP)

Date form received at SMOH or the national level:

Name of Patient:

Date of Birth (DOB): / / / / (Day/Month/Year

Sex: M=Male; F=Female
Patient’s Address:
Settlement/Village
Ward

Exact residential address:

Date seen at Health Facility (dd/mm/yyyy): / /

Number of vaccine doses received:

Date of last vaccination:

Close contact with infected poultry

Close contact with suspected or confirmed case of Avian influenza
Associated with an outbreak?
In/Out Patient
Outcome
Final Classification of case
Final Classification for Measles
Person completing form (Name) :
Title: Address:
Date form sent to LGA: / / (Day/Month/Year)
orting Form IDSR 001A

Immedia
From Health Fac
Influenza due to new subtype e.g Leprosy Lymphatic Filariasis Maternal Measles Meningitis Monkey
H5N1 deaths pox

/ (Day/Month/Year)

Urban:

LGA:

If applicable or If the patient is neonate or child, please write full name of mother and father of the patient

Date Health Facility notified LGA:

9 = unknown

For cases of Measles, NT (TT in mother), Yellow Fever, and Meningitis (For Measles, TT, YF - by card & for Menin
/ /
(Measles, Neonatal Tetanus (TT in mother), Yellow Fever and Meningitis only)
1 = Yes; 2 = No
1 = Yes; 2 = No
1 = Yes; 2 = No
1 = Inpatient; 2 = Outpatient
1 = Alive; 2 = Dead; 9 = Unknown
1 = Confirmed; 2 = Probable; 3 = Discarded; 4 = Suspect
1 = Laboratory Confirmed; 2 = Confirmed by Epidemiological linkage; 3 = Clinical Compatible; 4 = Discard; 5

Date Form Received at LGA: / / (Day/Month/Year)

 REPORTING LGA

Immediate/ Case-based Reporting Form

From Health Facility/Health Worker to LGA health team
Neonatal Noma Onchocerciasis Perinatal Pertusis Rabies (Dog bite) Rubella
Tetanus deaths
(NNT)

/ / (Day/Month/Year)

Age (If DOB unknown):

Rural:

ther of the patient

notified LGA: / /

TT, YF - by card & for Meningitis, by history)

Compatible; 4 = Discard; 5 = Suspect with lab pending

Signature:

Signature:
 REPORTING STATE
IDSR 001A

Trachoma Tuberculosis Viral Hemorrhagic Fever Yaw & endemic syphills or Yellow Fever
(TB) e.g. Lassa fever bejel

Year: Month (if <12):

State:

Date of Onset: / /
Yellow Fever Others/specify* e.g.Ebola, MERS SARS, Small pox,
Plague, Anthrax, Plague, Zika Virus, Chikungunya etc

Day (NNT only)

Lab Specimen Collection/Reporting Form (for Immedi
If Lab Specimen Collected

For Health Facility: If lab specimen is collected, complete the following information and send a copy of this form to the lab with the specimen.

Date of specimen collection: ______/_______/______ ________________

Type of specimen: Stool Blood

Date specimen sent to lab: ______/_______/_____

ID Number:

For the Lab: Complete this section and return the form to LGA/ health facility or clinician

Date lab received specimen: __/_______/______

Specimen Condition:

Disease/Condition:

Type of Test:

Result: + = Positive

P. Faliciparum
Malaria
P. Vivax

Cholera (culture)

Cholera direct exam; specify the method used: ______________________________

Culture

Meningitis: N meningitides Latex

Gram stain

Culture

Meningitis: S. pneumonia Latex

Gram stain

Culture

Meningitis: H. influenza Latex

Gram stain

Culture
Shigella dysenteriae
Type SD Type 1

Result: + = Positive

Yellow fever (IgM)

Measles (IgM)

Rubella (IgM)

Dengue (IgM)
Viral Detection
Ebola (IgM)
Viral Detection

Lassa (Ig M)

Marburg (IgM)

A/H5N1 (RT-PCR)

Other lab test (specify) Results:

Date lab sent results to LGA//health facility:

Name of lab sending results:

Other pending results:

Name of lab technician sending the results:

Date LGA/ receive lab results: ____/____/________

Date lab results sent to health facility by LGA/: _____/______/_______

Date lab results received at the health facility: _____/_______/________

rm (for Immediate Case-based Surveillance) IDSR 001B

f this form to the lab with the specimen.

CSF Others (Specify):

Adequate Not adequate

+ = Positive - = Negative P = pending

SD Type 1 Other Shigella types No Shigella

+ = Positive - = Negative I= Indeter.

_____ /_____ /________

Signature:

LGA/:
R 001B

No Shigella

P=Pending
 Line List – Reporting from Health Facility to LGA and for use during outbreaks (IDSR001C)
Health Facility: ______________________________ Ward _________________________ State: ________________

Disease or condition:_________________________________ Date received at LGA:______________________________ Date Sent to LGA:___________________________________

Record date Outcome

O=Out-patient; Village, Town and Date seen at Date onset of Number of doses of Other Other Record results of
CASE ID No Name (Surname in Capital) Sex Age1 laboratory A = Alive; Comments
I = In-patient Neighborhood health facility disease vaccine2 received variable variable laboratory testing
specimen collected D = Dead

·                      If LGA sends specimens to the laboratory, use the same case ID number in the NIE/ SSS/ LLLYY-NNNN format to identify the specimen.
·                      If health facility sends the laboratory specimen to the laboratory without passing through the LGA, then use the patient’s name to identify the specimen.

·                      NOTE: If more than 100 cases occur in a week at a health facility (e.g., for measles, cholera, and so on), do not line list them. Record the total number of cases only. If previously recorded cases die, update their status by completing a new row
with “died” in the “Outcome” column and “update record” in the Comments column.

1
Record age in months up through age 12 months. If patient is more than 12 months old, record age in years.
2
Exclude doses given within 14 days of onset of the disease.

NIE – Country Code, SSS – State Code, LLL – LGA Code, YY – Year, NNN – Patient Number
 Reporting LGA

Reporting Week

SN DISEASE 0-28 days

1 Acute Viral Hepatitis

2 Diarrhoea with dehydration (< 5yrs)
3 Diarrhoea with blood (Shigella)
4 Human African Trypanosomiasis (HAT)
5a Malaria
5b Malaria (severe)
5c Malaria (Pregnant Women)
6 Non-neonatal Tetanus
7 New HIV/ AIDS cases
8 Schistosomiasis
9 Snake Bite
10 Soil transmitted helminths
11 Typhoid fever

Name of Reporting Officer

 State

Year

Suspected cases
1-11 months 12-59 months 5-9 years 10-19 years
 LGA LEV
ROUTINE WEEKLY NOTIFICA
Total No. of Health Facilities

HFs Reporting T

es
20-40 years >40 years Total 0-28 days 1-11 months

Signat
 LGA LEVEL
NOTIFICATION FORM: IDSR 002
ealth Facilities (HFs) LGA Reporting Status

Fs Reporting Timely HFs Reporting

Lab confirmed cases

12-59 months 5-9 years 10-19 years 20-40 years

Signature
LGA Reporting Status (T / L / N)

HFs Reporting Late HFs Not Repo

D
>40 years Total 0-28 days 1-11 months

Date
 HFs Not Reporting

DEATHS
12-59 months 5-9 years 10-19 years 20-40 years
>40 years Total
 Reporting Health FacilitY (HF)

Reporting Week

SN DISEASE 0-28 days

1 Acute Viral Hepatitis

2 Diarrhoea with dehydration (< 5yrs)

3 Diarrhoea with blood (Shigella)

4 Human African Trypanosomiasis (HAT)

5a Malaria

5b Malaria (severe)

5c Malaria (Pregnant Women)

6 Non-neonatal Tetanus

7 New HIV/ AIDS cases

8 Schistosomiasis
 9 Snake Bite

10 Soil transmitted helminths

11 Typhoid fever

Name of Reporting Officer

 LGA

Year

Suspected cases
1-11 months 12-59 months 5-9 years 10-19 years 20-40 years
 HEALTH FACILITY LEVEL
ROUTINE WEEKLY NOTIFICATION FORM

State

Lab conf
>40 years Total 0-28 days 1-11 months 12-59 months
Signature
TY LEVEL
TION FORM: IDSR 002

Lab confirmed cases

5-9 years 10-19 years 20-40 years >40 years Total
ure
 DEATHS
0-28 days 1-11 months 12-59 months 5-9 years 10-19 years
Date
20-40 years >40 years Total
SN

1
1a
1b
1c
1d
xx
2
3
4
5
6
7
8
9
 Reporting LGA

Reporting Month

DISEASE

Sexually Transmitted Infections (STIs):

Vaginal discharge
Genital Ulcer
Urethral discharge
Others STIs
NON-COMMUNICABLE DISEASES / CONDITIONS / EVENTS
Adverse Events following immunization
Diabetes Mellitus (New cases)
Hypertension
Injuries (Road Traffic Accident)
Malnutrition in children under 5 years of age
MNS Disorder (Epilepsy, Schizorphernia depression etc)
Severe pneumonia in chlidren under 5 years of age
Sickle Cell Disorder (New cases)
Name of Reporting Officer
 State

Year

Cases out-patients

0-28 days 1-11 months 12-59 months 5-9 years

 LGA L
ROUTINE MONTHLY NOTIF
Total No. of Health

HFs Re

s out-patients

10-19 years 20-40 years >40 years Total 0-28 days

 LGA LEVEL
NTHLY NOTIFICATION FORM: IDSR 003
otal No. of Health Facilities (HFs)

HFs Reporting Timely

Cases in-patients

1-11 months 12-59 months 5-9 years 10-19 years

Signature
003
LGA Reporting Status (T / L / N)

HFs Reporting Late

Total cases in &

out patient
20-40 years >40 years Total 0-28 days
Date
 HFs Not Reporting

DEATHS

1-11 months 12-59 months 5-9 years 10-19 years

20-40 years >40 years Total
SN
1
1a
1b
1c
1d
xx
2
3
4
5
6
7
8
9
 Reporting Health FacilitY (HF)

Reporting Week

DISEASE
Sexually Transmitted Infections (STIs):
Vaginal discharge
Genital Ulcer
Urethral discharge
Others STIs
NON-COMMUNICABLE DISEASES / CONDITIONS / EVENTS
Adverse Events following immunization
Diabetes Mellitus (New cases)
Hypertension
Injuries (Road Traffic Accident)
Malnutrition in children under 5 years of age
MNS Disorder (Epilepsy, Schizorphernia depression etc)
Severe pneumonia in chlidren under 5 years of age
Sickle Cell Disorder (New cases)

Name of Reporting Officer

 LGA

Year

Cases out-patients

0-28 days 1-11 months 12-59 months 5-9 years 10-19 years
 LGA LEVEL
ROUTINE MONTHLY NOTIFICATION
State

20-40 years >40 years Total 0-28 days 1-11 months

Signature
 GA LEVEL
NOTIFICATION FORM: IDSR 003

Cases in-patients

12-59 months 5-9 years 10-19 years 20-40 years >40 years

Signature
 Total cases in & DE
out patient
Total 0-28 days 1-11 months 12-59 months

Date
 DEATHS

5-9 years 10-19 years 20-40 years >40 years Total

 Rumour Log
[Send this form immediately to your supervisor or nearby health facility
S/No
1 Name of Community Informants/Agents focal person reporting: _____________________________________
2 Telephone number: ______________________ Community: _______________________

3 Reporting date(day, month, year): _______/_________/___________

4 Type of illness/Condition/Event/Alert (please describe): ________________________________
5 Source of information: Observed/Print & Media/Social Media(Facebook/Twitter/Whatsapp), others Specify
6 When did this happen (Date: Day/Month/Year); Time
7 Where did this
Date/time this was
happen?
detected (Format: Day/Month/Year): Time:
(Location: community, ward/LGA, LGA)
8
9 How many people have been affected?
10 Has anyone died? If yes, how many
11 Are there sick or dead animals involved?
12 Is the event ongoing as at the time of this report?
13 If yes, is it increasing or decreasing or static
14 What action has been taken?
15 Has this been verified by health facility / LGA DSNO
or or nearby health facility]

___________
LGA______________________________

____
), others Specify