Event-Based Surveillance Form - 20171229

Event-based Surveillance Form EWARS | Bangladesh
1. General Information
Name of reporting officer
Phone number
2. Event description
Site
Location of event Zone
¨ Infectious (also fill section 3 below)

What is the likely hazard?
(tick ONE box only)
¨ Environmental (also fill section 4 below)
¨ Other (describe in comments in section 5 below)
Day Month Year
Date event was reported
¨ Community ¨ Media
¨ Mahji ¨ Health Worker
¨ Other
Where did the report come
from? (tick ONE box only)
If you have ticked ‘Other’, write additional details on source below:
¨ Phone ¨ Media
How was the information
received? (tick ONE box only) ¨ SMS ¨ Email
¨ Other
v2.1 20171229
3. Infectious hazards (if you ticked Infectious hazard - fill this section)
3.1 Which suspected disease is reported (tick ONE box only)
¨ AFP / Polio ¨ Meningitis

¨ Acute Jaundice Syndrome ¨ Pertussis
¨ Acute Watery Diarrhoea ¨ Maternal death
¨ Bloody diarrhoea ¨ Neonatal death
¨ Cholera ¨ Perinatal death
¨ Diphtheria ¨ Rabies
¨ Malaria ¨ Unknown
¨ Measles ¨ Viral Haemorrhagic Fever
¨ Other
If you have ticked ‘Other’, write additional details on signs and symptoms in the space below:
3.2 Number of reported cases

Cases Deaths
and deaths
<5
≥5
4. Environmental hazards (if you ticked Environmental hazard - fill this section)
4.1 Which environmental hazard is reported (tick ONE box only)
¨ Bird die-off ¨ Fish die-off

¨ Other ¨ Animal die-off
5. Additional comments
v2.1 20171229
Name of reporting officer John Smith

Phone number +88 123 4567
Site
Location of event
Kutupalong Extension
Zone
Zone XX
What is the likely hazard? (tick
ü
¨
¨
Infectious (also fill section 3 below)
Environmental (also fill section 4 below)
ONE box only)
¨ Other (describe in comments in section 5 below)
Day Month Year
Date event was reported 29 12 2017
ü
¨ Community ¨ Newspaper
¨ Mahji ¨ Health Worker
¨ Other
Where did the report come
from? (tick ONE box only)
If you have ticked ‘Other’, write additional details on source below:
How was the information

¨ü Phone ¨ Media
received? (tick ONE box only) ¨ SMS ¨ Email

¨ Other
v2.1 20171229
3. Infectious hazards (if you ticked Infectious hazard - fill this section)
3.1 Which suspected disease is reported (tick ONE box only)
¨ AFP / Polio ¨ Meningitis

¨ Acute Jaundice Syndrome ¨ Pertussis
¨ Acute Watery Diarrhoea ¨ Maternal death
¨ Bloody diarrhoea ¨ Neonatal death
¨ Cholera ¨ Perinatal death
ü
¨ Diphtheria ¨ Rabies
¨ Malaria ¨ Unknown
¨ Measles ¨ Viral Haemorrhagic Fever
¨ Other
3.2 Number of reported cases

Cases Deaths
and deaths
<5 2 1
≥5 0 0
4. Environmental hazards (if you ticked Environmental hazard - fill this section)
4.1 Which environmental hazard is reported (tick ONE box only)
¨ Bird die-off ¨ Fish die-off

¨ Other ¨ Animal die-off
Cases are new arrivals that were not vaccinated.
v2.1 20171229
Name of reporting officer Name of person who completed the report
Phone number Phone number
Enter the name of the site and zone where the event has been
Location of event
detected
Tick box to indicate a single type of hazard. If multiple hazards

What is the likely hazard?
are suspected, then complete a different form for each
Date event was reported Date of event (dd / mm / yyy)
Where did the report come Tick box to indicate the source of information on the event. If
from? Other is ticked, then specify what this is in the space below.
How was the information Tick box to indicate how the information on the event was
received? received by the person completing the report.
3. Infectious hazards
If an Infectious hazard has been reported, then fill in this section.
Tick box to indicate a single suspected disease. If Other is

3.1 Which suspected disease is ticked, then specify what this is in the space below. If multiple
reported diseases are suspected, then complete a different form for
each.
3.2 Number of reported cases Enter the number of cases and deaths that are reported.
and deaths
v2.1 20171229
4. Environmental hazards
If an Environmental hazard has been ticked as the type of event, then fill in this section.
Tick box to indicate a single type of hazard. If Other is ticked,

4.1 Which suspected disease is then specify what this is in the space below. If multiple
reported environmental hazards are suspected, then complete a
different form for each.
Enter additional comments related to the event. For hazards
Comments
ticked as “Other” fill in the information here
v2.1 20171229

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Event-based Surveillance Form EWARS | Bangladesh

Name of reporting officer

Location of event Zone

¨ Infectious (also fill section 3 below)

3.1 Which suspected disease is reported (tick ONE box only)

¨ AFP / Polio ¨ Meningitis

3.2 Number of reported cases

4.1 Which environmental hazard is reported (tick ONE box only)

¨ Bird die-off ¨ Fish die-off

Name of reporting officer John Smith

How was the information

received? (tick ONE box only) ¨ SMS ¨ Email

3.1 Which suspected disease is reported (tick ONE box only)

¨ AFP / Polio ¨ Meningitis

3.2 Number of reported cases

4.1 Which environmental hazard is reported (tick ONE box only)

¨ Bird die-off ¨ Fish die-off

Cases are new arrivals that were not vaccinated.

Name of reporting officer Name of person who completed the report

Phone number Phone number

Tick box to indicate a single type of hazard. If multiple hazards

Date event was reported Date of event (dd / mm / yyy)

Tick box to indicate a single suspected disease. If Other is

Tick box to indicate a single type of hazard. If Other is ticked,

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