Version 2022

Epidemic-prone Disease Case Report Form

Case Surveillance Typhoid and Paratyphoid Fever (ICD 10 Code: A01.0, A01.1-A01.4)

Region: ____________________________ Province: ___________________________ Municipality/City: ________________________________________

Name of DRU: _________________________________________________________________ Type: ⃞RHU ⃞CHO/MHO/PHO ⃞Gov’t Hospital ⃞Private Hospital
Address: _________________________________________________________________ ⃞Clinic ⃞Gov’t Laboratory ⃞Private Laboratory ⃞Airport/Seaport
Name of Interviewer: _____________________________________________________________ Type of site: ⃞Sentinel ⃞Non-sentinel

Indige- Con- Date of Place of Date Admitted/ Date onset of

Patient Civil Complete Current Complete Permanent nous sulted Admitted?
Patient’s Full Name Age Sex Date of Birth FIRST Consultation Seen/ illness (FIRST
No. Status Address Address People ? consultation Consulted symptoms)

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Age: Indicate
D - days S-Single
Response M-Married Specify House # Street/ Specify House # Street/ Please
M - months
Codes / Indicate Last name, First name, Sep- Purok/Subdivision, Ba- Purok/Subdivision, specify Y - Yes Name of Y - Yes
Yr. - years mm/dd/yyyy mm/dd/yyyy mm/dd/yyyy mm/dd/yyyy
Instruc- Middle name Separated rangay, Municipality/ Barangay, Municipality/ what N- No Facility N- No
Sex: W-
tions City, Province, Region City, Province, Region tribe
F - Female Widowed
M - Male

Case Definition:
• Suspected case: A person with an illness characterized by insidious onset of sustained fever, headache,
• Confirmed case: A suspected or probable case that is laboratory confirmed.
malaise, anorexia, relative bradycardia, constipation or diarrhea, and non-productive cough for 5 days or
more. Laboratory Confirmation:
• Probable case:
 A suspected case that is positive in Typhoid Rapid Diagnostic Test, or • Laboratory confirmation by culture or molecular methods of Salmonella typhi or detection of Salmonella typhi or Sal-
monella paratyphi DNA from a normally sterile site.
 A suspected case that is epidemiologically linked to a confirmed case in an outbreak.
Deliberately providing false or misleading, personal information on the part of the patient, or the next of kin in case of patient’s incapacity, may constitute non-cooperation punishable under the Republic Act. No. 11332
 Version 2022
Epidemic-prone Disease Case Report Form
Case Surveillance Typhoid and Paratyphoid Fever (ICD 10 Code: A01.0, A01.1-A01.4)

Patient’s Full Name Age Date of Birth Date of Specimen Laboratory Laboratory Case Date of death
Patient No. Sex Organism Outcome
Collected Test Done Result Classification

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Widal’s Test
Age: Indicate Typhi Dot
D - days Tubex
P– Positive Salmonella typhi
Response M - months Blood Culture S—Suspect
Indicate Last name, First name, Middle N– Negative Salmonella paratyphi A - Alive
Codes / Instruc- Yr. - years mm/dd/yyyy mm/dd/yyyy Stool Culture P—Probable mm/dd/yyyy
name ND– Not done U– Unknown D - Died
tions Sex: Serotyping/ C– Confirmed
F - Female U- Unknown NA– Not applicable
Serogrouping
M - Male ND– Not done
U– Unknown

Case Definition:
• Suspected case: A person with an illness characterized by insidious onset of sustained fever, headache, • Confirmed case: A suspected or probable case that is laboratory confirmed.
malaise, anorexia, relative bradycardia, constipation or diarrhea, and non-productive cough for 5 days or
more. Laboratory Confirmation:
• Probable case:
 A suspected case that is positive in Typhoid Rapid Diagnostic Test, or • Laboratory confirmation by culture or molecular methods of Salmonella typhi or detection of Salmonella typhi or Sal-
monella paratyphi DNA from a normally sterile site.
 A suspected case that is epidemiologically linked to a confirmed case in an outbreak.

Deliberately providing false or misleading, personal information on the part of the patient, or the next of kin in case of patient’s incapacity, may constitute non-cooperation punishable under the Republic Act. No. 11332