LinkId Text Cardinality Type Description & Constraints SOTMeasles-AFRO-MRCIF AFRO Measles Case Investigation Questionnaire Questionnaire http://worldhealthorganization.github.io/smart-ot/Questionnaire/SOTMeasles-AFRO-MRCIF#0.2.1 investigationForm Measles/ rubella suspected case investigation form for immediate reporting 0..1 group description Complete this form for: health facility / district to the national level 0..1 display reportingSource For Official Use Only -to be completed by the district / national team 0..1 group caseID EPID Number: Country-Province-District-year-onset-case # 0..1 string reportingInstitution Reporting Institution 0..1 group reportingFacility Reporting Health Facility 0..1 string locality Reporting District 0..1 string DateReportedNational Date the form was received at national level 0..1 date demographics IDENTIFICATION: 0..1 group name Name of Patient 0..1 string DoB Date of Birth 0..1 date ageOnset If date of birth is unknown, age 0..1 integer sex Sex 0..1 choice Value Set: SOT Biological Sex address Address 0..1 string localityType Urban/Rural 0..1 choice Value Set: SOT Measles Locality Type vaccinationStatus VACCINATION STATUS: 0..* group vaccineType Type of Vaccine received 0..1 choice Value Set: SOT Measles Vaccine Type noOfDoses Number of measles containing vaccine doses received in routine EPI and/or SIAs -valid values: 1 - 4 doses 0..1 choice Value Set: SOT Measles No Of Doses lastDoseDate Date of last dose 0..1 date caseInvestigation CASE INVESTIGATION: 0..* group dateReported Date case was notified to the district 0..1 date DateOfConsultation Date Of case investigation 0..1 date rashOnsetDate Date of rash onset 0..1 date clinical Clinical HISTORY: 0..1 group fever Fever 0..1 choice Value Set: Yes No Unknown rash Generalized Rash 0..1 choice Value Set: Yes No Unknown cough Cough 0..1 choice Value Set: Yes No Unknown conjunctivitis Red Eyes 0..1 choice Value Set: Yes No Unknown coryza Running nose 0..1 choice Value Set: Yes No Unknown lymphadenopathy Swollen lymph nodes behind ears 0..1 choice Value Set: Yes No Unknown jointPain Joint pain/swelling 0..1 choice Value Set: Yes No Unknown admitted In/out-patient 0..1 choice Value Set: Yes No Unknown outcome Outcome 0..1 choice Value Set: Patient Clinical Course Outcome travelledOutside History of travel outside the village/ town/ district in last 7 - 21 days before onset of rash 0..1 choice Value Set: Yes No Unknown infectionSetting Most probable place of exposure to measles/ rubella: district 0..1 string classification FINAL CLASSIFICATION: 0..1 group finalClassification Final Classification 0..1 choice Value Set: FinalClassification reportedBy Person Completing the form: Name 0..1 string laboratoryResults FOR SUSPECTED MEASLES/ RUBELLA CASES WITH LAB SPECIMENS 0..1 group sampleType Specimen source 0..1 choice Value Set: Sample Type collectionDate Date specimen obtained 0..1 date specimenSentDate Date specimen was sent to lab 0..1 date specimenReceivedDate Date Received 0..1 date testPerformed Type of test 0..1 choice Value Set: AFRO MRCIF Test Type result Result 0..1 choice Value Set: Result specifyVirus Virus Detection -Genotype 0..1 string labName Laboratory Name 0..1 string Documentation for this format
AFRO Measles Case Investigation Questionnaire
Measles/ rubella suspected case investigation form for immediate reporting
Complete this form for: health facility / district to the national level
For Official Use Only -to be completed by the district / national team
EPID Number: Country-Province-District-year-onset-case #
Date the form was received at national level
Number of measles containing vaccine doses received in routine EPI and/or SIAs -valid values: 1 - 4 doses
History of travel outside the village/ town/ district in last 7 - 21 days before onset of rash
Most probable place of exposure to measles/ rubella: district
FOR SUSPECTED MEASLES/ RUBELLA CASES WITH LAB SPECIMENS