LinkId Text Definition Answer Response1 Questionnaire:Measles Case Investigation Questionnaire investigationForm Investigation Form for Measles/Rubella reportingSource Section I: Identification of the Reporting Institution initialDiagnosis Initial Diagnosis Initial Diagnosis Code System 1: Measles caseID Case Number 123 reportingInstitution Reporting Institution reportingFacility Health Service Name hservicename telephone Health Service Telephone 12345678 country Country Utopia municipality Municipality Middle state Province/State Nowhere locality Locality/Neighborhood Right reportedBy Reported By Dr. WHO DateOfConsultation Date Of Consultation 2023-10-10 DateOfHomeVisit Date Of Home Visit 2023-10-02 dateReported Date Reported - Local 2023-10-02 DateReportedNational Date Reported - National 2023-10-03 DetectedBy Detected By Detected By Code System 88: Other TypeOfProviderReporting Type Of Provider Reporting Type of Provider Code System 1: Public demographics Section II: Patient Information name Patient’s first and last names John Doe guardian Name of the mother or guardian Jane Doe address Address Coast street telephone Telephone 0987654321 landmark Landmarks to locate the house Fountain occupation Patient’s Occupation Busy localityType Type of locality Locality Type Code System 1: Urban workAddress Work or school address HomeStreet sex Patient’s sex AdministrativeGender male: Male DoB Patient’s Date of Birth 2010-10-16 vaccinationStatus Section III: Vaccination History vaccineType Type of Vaccine* Vaccine Type 1: Measles noOfDoses Number of doses** Number of Doses 0: Zero dose sourceOfInformation Source of vaccination Information † Vaccine Info Source HealthServices: Health Services clinical Section IV: Clinical Data; Follow-up & Treatment fever Fever? Yes No Unknown No: No rash Rash? Yes No Unknown Yes: Yes rashDuration If Yes, duration of the rash(in days) 3 cough Cough? Yes No Unknown Yes: Yes conjunctivitis Conjunctivitis? Yes No Unknown Yes: Yes coryza Coryza? Yes No Unknown No: No koplikSpots Koplik Spots? Yes No Unknown No: No lymphadenopathy Lymphadenopathy? Yes No Unknown No: No jointPain Arthralgia? Yes No Unknown No: No pregnancy Is the patient pregnant? Yes No Unknown No: No admitted Hospitalized? Yes No Unknown No: No outcome Death? Patient Clinical Course Outcome Sick: Still sick laboratoryResults Section V: Specimens & Laboratory Testing specimenNumber Specimen number* Specimen Number Code System 1: First Sample sampleType Type of specimen** Sample Type Code System 1: Serum Documentation for this format
Section I: Identification of the Reporting Institution
Section IV: Clinical Data; Follow-up & Treatment
Section V: Specimens & Laboratory Testing