LinkId Text Cardinality Type Description & Constraints Questionnaire-SOTMeasles Measles Case Investigation Questionnaire Questionnaire http://worldhealthorganization.github.io/smart-ot/Questionnaire/Questionnaire-SOTMeasles#0.2.1 investigationForm Investigation Form for Measles/Rubella 0..1 group description Complete 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..1 display reportingSource Section I: Identification of the Reporting Institution 0..1 group initialDiagnosis Initial Diagnosis 0..1 choice Value Set: SOT Measles Initial Diagnosis caseID Case Number 0..1 string reportingInstitution Reporting Institution 0..1 group reportingFacility Health Service Name 0..1 string telephone Health Service Telephone 0..1 string country Country 0..1 string municipality Municipality 0..1 string state Province/State 0..1 string locality Locality/Neighborhood 0..1 string reportedBy Reported By 0..1 string DateOfConsultation Date Of Consultation 0..1 date DateOfHomeVisit Date Of Home Visit 0..1 date dateReported Date Reported - Local 0..1 date DateReportedNational Date Reported - National 0..1 date DetectedBy Detected By 0..1 choice Value Set: SOT Measles Detected By TypeOfProviderReporting Type Of Provider Reporting 0..1 choice Value Set: SOT Measles Provider Type specifyother Specify 0..1 string Enable When: TypeOfProviderReporting = Other (Type of Provider Code System#88) demographics Section II: Patient Information 0..1 group name Patient’s first and last names 0..1 string guardian Name of the mother or guardian 0..1 string address Address 0..1 string telephone Telephone 0..1 string landmark Landmarks to locate the house 0..1 string occupation Patient’s Occupation 0..1 string localityType Type of locality 0..1 choice Value Set: SOT Measles Locality Type workAddress Work or school address 0..1 string sex Patient’s sex 0..1 choice Value Set: SOT Biological Sex DoB Patient’s Date of Birth 0..1 date ageOnset If date of birth is unknown, age 0..1 integer vaccinationStatus Section III: Vaccination History 0..* group vaccineType Type of Vaccine* 0..1 choice Value Set: SOT Measles Vaccine Type noOfDoses Number of doses** 0..1 choice Value Set: SOT Measles No Of Doses lastDoseDate Date of last dose 0..1 date sourceOfInformation Source of vaccination Information † 0..1 choice Value Set: Vaccine Info Source clinical Section IV: Clinical Data; Follow-up & Treatment 0..1 group fever Fever? 0..1 choice Value Set: Yes No Unknown temperature If Yes, temperature (°) 0..1 decimal Enable When: fever = Yes (Yes No Unknown#Yes) dateOfFeverOnset Date of fever onset 0..1 date Enable When: fever = Yes (Yes No Unknown#Yes) rash Rash? 0..1 choice Value Set: Yes No Unknown rashDuration If Yes, duration of the rash(in days) 0..1 integer Enable When: rash = Yes (Yes No Unknown#Yes) rashOnsetDate Date of rash onset 0..1 date Enable When: rash = Yes (Yes No Unknown#Yes) rashType Type of rash 0..1 choice Enable When: rash = Yes (Yes No Unknown#Yes) Value Set: Rash Type cough Cough? 0..1 choice Value Set: Yes No Unknown conjunctivitis Conjunctivitis? 0..1 choice Value Set: Yes No Unknown coryza Coryza? 0..1 choice Value Set: Yes No Unknown koplikSpots Koplik Spots? 0..1 choice Value Set: Yes No Unknown lymphadenopathy Lymphadenopathy? 0..1 choice Value Set: Yes No Unknown jointPain Arthralgia? 0..1 choice Value Set: Yes No Unknown pregnancy Is the patient pregnant? 0..1 choice Value Set: Yes No Unknown monthsPregnant Weeks of pregnancy (01-42) 0..1 integer Enable When: pregnancy = Yes (Yes No Unknown#Yes) placeOfBirth If Yes, Place where birth will likely take place 0..1 string Enable When: pregnancy = Yes (Yes No Unknown#Yes) admitted Hospitalized? 0..1 choice Value Set: Yes No Unknown admittedHCFName Hospital name 0..1 string Enable When: admitted = Yes (Yes No Unknown#Yes) admissionDate If Yes, Date of admission 0..1 date Enable When: admitted = Yes (Yes No Unknown#Yes) hospitalRecordNumber Hospital record number 0..1 string Enable When: admitted = Yes (Yes No Unknown#Yes) outcome Death? 0..1 choice Value Set: Patient Clinical Course Outcome outcomeDate If Yes, Date of death 0..1 date Enable When: outcome = Death (Patient Clinical Course Outcome#Death) primaryCauseOfDeath Primary cause of death 0..1 string Enable When: outcome = Death (Patient Clinical Course Outcome#Death) diseaseAdditionalInfo Comments 0..1 string laboratoryResults Section V: Specimens & Laboratory Testing 0..1 group specimenNumber Specimen number* 0..1 choice Value Set: Specimen Number sampleType Type of specimen** 0..1 choice Value Set: Sample Type collectionDate Date specimen obtained 0..1 date labName Laboratory Name 0..1 string specimenSentDate Date specimen was sent to lab 0..1 date specimenReceivedDate Date Received 0..1 date sampleId # specimen ID in lab. 0..1 string testPerformed Type of test 0..1 choice Value Set: Test Performed antigen Antigen 0..1 choice Value Set: Antigen result Result 0..1 choice Value Set: Result resultDate Date of Results 0..1 date specifyVirus If 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..1 string contactTracing Section VI: Investigation 0..1 group caseSearchConducted Were active case-searches conducted? 0..1 choice Value Set: Yes No Unknown noOfsuspectCases If Yes, Number of suspect cases detected during active case-search 0..1 integer Enable When: caseSearchConducted = Yes (Yes No Unknown#Yes) pregnantContact Was the patient in contact with any pregnant woman? 0..1 choice Value Set: Yes No Unknown pregnantContactNames If Yes, Name(s) 0..1 string Enable When: pregnantContact = Yes (Yes No Unknown#Yes) localCasesPresent Are there other cases present in the case’s municipality of residence? 0..1 choice Value Set: LocalCasesPresent travelledOutside Did the patient travel outside his/her province/state of residence 7-23 days before rash onset? 0..1 choice Value Set: Yes No Unknown travelDetails If Yes,: 0..* group Enable When: travelledOutside = Yes (Yes No Unknown#Yes) placeOfTravel Cities/Countries 0..1 string arrivalDate Date of arrival 0..1 date departureDate Date of departure 0..1 date infectionSetting Setting where infected? 0..1 choice Value Set: InfectionSetting specifyInfectionSetting Specify 0..1 string Enable When: infectionSetting = Others (InfectionSetting#88) epiData Section VII: Response Measures 0..1 group ringVaccination Ring vaccination? 0..1 choice Value Set: Yes No Unknown dateStarted Date started 0..1 date Enable When: ringVaccination = Yes (Yes No Unknown#Yes) dateEnded Date Ended 0..1 date Enable When: ringVaccination = Yes (Yes No Unknown#Yes) noOfDosesRingVaccination Number of doses given during ring vaccination 0..1 integer Enable When: ringVaccination = Yes (Yes No Unknown#Yes) rapidCoverageMonitioring Was rapid coverage monitoring done 0..1 choice Value Set: Yes No Unknown percentVaccinated If yes, what % of vaccinated persons was found? 0..1 integer Enable When: rapidCoverageMonitioring = Yes (Yes No Unknown#Yes) contactTracingDone Were the contacts followed for up to 30 days after the date of the rash onset of the case? 0..1 choice Value Set: Yes No Unknown lastFollowUp If yes, date of the last day of contact follow-up 0..1 date Enable When: contactTracingDone = Yes (Yes No Unknown#Yes) classification Section VIII: Classification 0..1 group finalClassification Final Classification 0..1 choice Value Set: FinalClassification confirmationBasis Basis for confirmation 0..1 choice Value Set: ConfirmationBasis countryImportation If Imported or Import-related, Country of importation 0..1 string Enable When: confirmationBasis = Laboratory (Confirmation Basis#1) discardingBasis Basis for discarding 0..1 choice Value Set: DiscardingBasis sourceOfInfection For confirmed cases, Source of infection 0..1 choice Value Set: SourceOfInfection contact Contact of another case? 0..1 choice Value Set: Yes No Unknown contactCaseNo Contact of (or epidemiologically-linked to) case number 0..1 string Enable When: contact = Yes (Yes No Unknown#Yes) classifiedBy Classified by 0..1 string classificationDate Date of final classification 0..1 date Documentation for this format
Measles Case Investigation Questionnaire
Complete 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.
Section I: Identification of the Reporting Institution
Section IV: Clinical Data; Follow-up & Treatment
If Yes, Place where birth will likely take place
Section V: Specimens & Laboratory Testing
If 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)
If Yes, Number of suspect cases detected during active case-search
Was the patient in contact with any pregnant woman?
Are there other cases present in the case’s municipality of residence?
Did the patient travel outside his/her province/state of residence 7-23 days before rash onset?
Number of doses given during ring vaccination
If yes, what % of vaccinated persons was found?
Were the contacts followed for up to 30 days after the date of the rash onset of the case?
If yes, date of the last day of contact follow-up
If Imported or Import-related, Country of importation
For confirmed cases, Source of infection
Contact of (or epidemiologically-linked to) case number