WHO SMART Guideline: Surveillance and Outbreak Toolkit
0.2.1 - CI Build International flag

WHO SMART Guideline: Surveillance and Outbreak Toolkit, published by WHO. This is not an authorized publication; it is the continuous build for version 0.2.1. This version is based on the current content of https://github.com/WorldHealthOrganization/smart-ot and changes regularly. See the Directory of published versions

Questionnaire: Measles Case Investigation Questionnaire

Branch:
LinkIdTextCardinalityTypeDescription & Constraintsdoco
.. Questionnaire-SOTMeaslesMeasles Case Investigation QuestionnaireQuestionnairehttp://worldhealthorganization.github.io/smart-ot/Questionnaire/Questionnaire-SOTMeasles#0.2.1
... investigationFormInvestigation Form for Measles/Rubella0..1group
.... descriptionComplete this form for: Any person in whom a health care worker suspects measles or rubella infection or a patient with fever and rash. The health worker should attempt to collect epidemiological and clinical data , as well as a blood sample , on the first contact with the patient. This contact with the patient might be the only one.0..1display
.... reportingSourceSection I: Identification of the Reporting Institution0..1group
..... initialDiagnosisInitial Diagnosis0..1choiceValue Set: SOT Measles Initial Diagnosis
..... caseIDCase Number0..1string
..... reportingInstitutionReporting Institution0..1group
...... reportingFacilityHealth Service Name0..1string
...... telephoneHealth Service Telephone0..1string
...... countryCountry0..1string
...... municipalityMunicipality0..1string
...... stateProvince/State0..1string
...... localityLocality/Neighborhood0..1string
..... reportedByReported By0..1string
..... DateOfConsultationDate Of Consultation0..1date
..... DateOfHomeVisitDate Of Home Visit0..1date
..... dateReportedDate Reported - Local0..1date
..... DateReportedNationalDate Reported - National0..1date
..... DetectedByDetected By0..1choiceValue Set: SOT Measles Detected By
..... TypeOfProviderReportingType Of Provider Reporting0..1choiceValue Set: SOT Measles Provider Type
..... specifyotherSpecify0..1stringEnable When: TypeOfProviderReporting = Other (Type of Provider Code System#88)
.... demographicsSection II: Patient Information0..1group
..... namePatient’s first and last names0..1string
..... guardianName of the mother or guardian0..1string
..... addressAddress0..1string
..... telephoneTelephone0..1string
..... landmarkLandmarks to locate the house0..1string
..... occupationPatient’s Occupation0..1string
..... localityTypeType of locality0..1choiceValue Set: SOT Measles Locality Type
..... workAddressWork or school address0..1string
..... sexPatient’s sex0..1choiceValue Set: SOT Biological Sex
..... DoBPatient’s Date of Birth0..1date
..... ageOnsetIf date of birth is unknown, age0..1integer
.... vaccinationStatusSection III: Vaccination History0..*group
..... vaccineTypeType of Vaccine*0..1choiceValue Set: SOT Measles Vaccine Type
..... noOfDosesNumber of doses**0..1choiceValue Set: SOT Measles No Of Doses
..... lastDoseDateDate of last dose0..1date
..... sourceOfInformationSource of vaccination Information †0..1choiceValue Set: Vaccine Info Source
.... clinicalSection IV: Clinical Data; Follow-up & Treatment0..1group
..... feverFever?0..1choiceValue Set: Yes No Unknown
..... temperatureIf Yes, temperature (°)0..1decimalEnable When: fever = Yes (Yes No Unknown#Yes)
..... dateOfFeverOnsetDate of fever onset0..1dateEnable When: fever = Yes (Yes No Unknown#Yes)
..... rashRash?0..1choiceValue Set: Yes No Unknown
..... rashDurationIf Yes, duration of the rash(in days)0..1integerEnable When: rash = Yes (Yes No Unknown#Yes)
..... rashOnsetDateDate of rash onset0..1dateEnable When: rash = Yes (Yes No Unknown#Yes)
..... rashTypeType of rash0..1choiceEnable When: rash = Yes (Yes No Unknown#Yes)
Value Set: Rash Type
..... coughCough?0..1choiceValue Set: Yes No Unknown
..... conjunctivitisConjunctivitis?0..1choiceValue Set: Yes No Unknown
..... coryzaCoryza?0..1choiceValue Set: Yes No Unknown
..... koplikSpotsKoplik Spots?0..1choiceValue Set: Yes No Unknown
..... lymphadenopathyLymphadenopathy?0..1choiceValue Set: Yes No Unknown
..... jointPainArthralgia?0..1choiceValue Set: Yes No Unknown
..... pregnancyIs the patient pregnant?0..1choiceValue Set: Yes No Unknown
..... monthsPregnantWeeks of pregnancy (01-42)0..1integerEnable When: pregnancy = Yes (Yes No Unknown#Yes)
..... placeOfBirthIf Yes, Place where birth will likely take place0..1stringEnable When: pregnancy = Yes (Yes No Unknown#Yes)
..... admittedHospitalized?0..1choiceValue Set: Yes No Unknown
..... admittedHCFNameHospital name0..1stringEnable When: admitted = Yes (Yes No Unknown#Yes)
..... admissionDateIf Yes, Date of admission0..1dateEnable When: admitted = Yes (Yes No Unknown#Yes)
..... hospitalRecordNumberHospital record number0..1stringEnable When: admitted = Yes (Yes No Unknown#Yes)
..... outcomeDeath?0..1choiceValue Set: Patient Clinical Course Outcome
..... outcomeDateIf Yes, Date of death0..1dateEnable When: outcome = Death (Patient Clinical Course Outcome#Death)
..... primaryCauseOfDeathPrimary cause of death0..1stringEnable When: outcome = Death (Patient Clinical Course Outcome#Death)
..... diseaseAdditionalInfoComments0..1string
.... laboratoryResultsSection V: Specimens & Laboratory Testing0..1group
..... specimenNumberSpecimen number*0..1choiceValue Set: Specimen Number
..... sampleTypeType of specimen**0..1choiceValue Set: Sample Type
..... collectionDateDate specimen obtained0..1date
..... labNameLaboratory Name0..1string
..... specimenSentDateDate specimen was sent to lab0..1date
..... specimenReceivedDateDate Received0..1date
..... sampleId# specimen ID in lab.0..1string
..... testPerformedType of test0..1choiceValue Set: Test Performed
..... antigenAntigen0..1choiceValue Set: Antigen
..... resultResult0..1choiceValue Set: Result
..... resultDateDate of Results0..1date
..... specifyVirusIf virus was detected, specify viral genotype: (Measles: A, B1, B2, B3, C1, C2, D1, D2, D3, D4, D5, D6, D7, D8, D9, D10, E, F, G1, G2, G3, H1, H2. Rubella: 1a, 1B, 1C, 1D, 1E, 1F, 1g, 2A, 2B, 2c)0..1string
.... contactTracingSection VI: Investigation0..1group
..... caseSearchConductedWere active case-searches conducted?0..1choiceValue Set: Yes No Unknown
..... noOfsuspectCasesIf Yes, Number of suspect cases detected during active case-search0..1integerEnable When: caseSearchConducted = Yes (Yes No Unknown#Yes)
..... pregnantContactWas the patient in contact with any pregnant woman?0..1choiceValue Set: Yes No Unknown
..... pregnantContactNamesIf Yes, Name(s)0..1stringEnable When: pregnantContact = Yes (Yes No Unknown#Yes)
..... localCasesPresentAre there other cases present in the case’s municipality of residence?0..1choiceValue Set: LocalCasesPresent
..... travelledOutsideDid the patient travel outside his/her province/state of residence 7-23 days before rash onset?0..1choiceValue Set: Yes No Unknown
..... travelDetailsIf Yes,:0..*groupEnable When: travelledOutside = Yes (Yes No Unknown#Yes)
...... placeOfTravelCities/Countries0..1string
...... arrivalDateDate of arrival0..1date
...... departureDateDate of departure0..1date
..... infectionSettingSetting where infected?0..1choiceValue Set: InfectionSetting
..... specifyInfectionSettingSpecify0..1stringEnable When: infectionSetting = Others (InfectionSetting#88)
.... epiDataSection VII: Response Measures0..1group
..... ringVaccinationRing vaccination?0..1choiceValue Set: Yes No Unknown
..... dateStartedDate started0..1dateEnable When: ringVaccination = Yes (Yes No Unknown#Yes)
..... dateEndedDate Ended0..1dateEnable When: ringVaccination = Yes (Yes No Unknown#Yes)
..... noOfDosesRingVaccinationNumber of doses given during ring vaccination0..1integerEnable When: ringVaccination = Yes (Yes No Unknown#Yes)
..... rapidCoverageMonitioringWas rapid coverage monitoring done0..1choiceValue Set: Yes No Unknown
..... percentVaccinatedIf yes, what % of vaccinated persons was found?0..1integerEnable When: rapidCoverageMonitioring = Yes (Yes No Unknown#Yes)
..... contactTracingDoneWere the contacts followed for up to 30 days after the date of the rash onset of the case?0..1choiceValue Set: Yes No Unknown
..... lastFollowUpIf yes, date of the last day of contact follow-up0..1dateEnable When: contactTracingDone = Yes (Yes No Unknown#Yes)
.... classificationSection VIII: Classification0..1group
..... finalClassificationFinal Classification0..1choiceValue Set: FinalClassification
..... confirmationBasisBasis for confirmation0..1choiceValue Set: ConfirmationBasis
..... countryImportationIf Imported or Import-related, Country of importation0..1stringEnable When: confirmationBasis = Laboratory (Confirmation Basis#1)
..... discardingBasisBasis for discarding0..1choiceValue Set: DiscardingBasis
..... sourceOfInfectionFor confirmed cases, Source of infection0..1choiceValue Set: SourceOfInfection
..... contactContact of another case?0..1choiceValue Set: Yes No Unknown
..... contactCaseNoContact of (or epidemiologically-linked to) case number0..1stringEnable When: contact = Yes (Yes No Unknown#Yes)
..... classifiedByClassified by0..1string
..... classificationDateDate of final classification0..1date

doco Documentation for this format