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AFP Close Contact Form

Close contact form 2022

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cobiestacio
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58 views1 page

AFP Close Contact Form

Close contact form 2022

Uploaded by

cobiestacio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Philippine Integrated Disease

Surveillance and Response


AFP Close Contact Form

Name of AFP Case: ______________________________________________________________________

Address: _________________________________________________________________

Total no.
Relationship to With paralysis/ of OPV/ Date Stool 1
Name Age Sex Date of Birth Date of Last Dose Results
the case weakness? IPV Dose Taken
Taken

1
_____/_____/____ ____/_____/____ ____/_____/____

2
_____/_____/____ ____/_____/____ ____/_____/____

3
_____/_____/____ ____/_____/____ ____/_____/____

4
_____/_____/____ ____/_____/____ ____/_____/____

5
_____/_____/____ ____/_____/____ ____/_____/____

Relationship: Y—Yes
Dose:
Sibling N– No WPV
Response 0
Sex: Household member Sabin-like
Codes / Indicate First name, Middle name, 1
Age Years F - Female mm/dd/yy Schoolmate If Yes, assess if the mm/dd/yy mm/dd/yy VDPV
Instruc- Last name 2
M - Male Playmate case fits the AFP NEG
tions 3
Others (Specify) Case Definition and NPEV
>3
Fill-out AFP CIF

Case Definition/Classification:

Suspect Case
 An AFP case is defined as a child less than 15 years of age presenting with recent or sudden onset of floppy paralysis or muscle weakness of the limbs due to any cause, OR

 Any person of any age with paralytic illness if poliomyelitis is suspected by a clinician.

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