S.P.E.E.D.

SYNDROMIC REPORTING FORM – 1

(HEALTH CENTERS, BHS, TEMPORARY AND MOBILE CLINICS)

Province: _____________ City/Municipality:______________. Barangay:_________

Name of Reporting Health Unit: __________________________________________

Population size of Evacuation Centre: < 5 yrs____________ > 5 yrs____________

Name of Reporting Officer: ___________ Mobile Number: ___________Date submitted: ________

HF Code (Health Facility Code):___________________
SMS Format (daily): HF HFCODE MM/DD/YY POP 0 0 DISEASECODE 0 0 0 0
SMS Format (alert): HF HFCODE ALERT DISEASECODE 0 0 0 0

<5 years old >5 years old

# Disease Syndrome / Health event
Cases Deaths Cases Deaths
1 Fever (FEV)

2 :Cough, colds or sore throat with or without fever (ARI)

3 Fever with rash (MEA)
4 Fever with spontaneous bleeding (i.e. nose bleeding, gum bleeding) (AHF)
Fever with severe headache and stiff-neck (fever and bulging fontanels in children
5
<12months, or refusal to suckle) (MEN)
Fever with headache, muscle pains and any of the following: eye irritation,
6
jaundice, skin rash, scanty urination (LEP)
7 Yellow eyes or skin with or without fever (AJS)
8 Fever with other symptoms not listed above (FOS)
9 Loose stools, 3 or more in the past 24hrs with or without dehydration (AWD)
10 Loose stools with visible blood (ABD)
11 Open wounds and bruises (WBS)
12 Fractures (FRS)
13 Skin disease (SDS)
14 Animal bites (ANB)
15 Eye itchiness, redness with or without discharge (CON)
16 Spasms of neck and jaw (lock jaw) (TET)
17 High blood pressure >140/90 (HBP)
18 Known diabetes (KDM)
19 Difficulty in breathing and wheezing (AAA)
Floppy paralysis of the limbs which occurred recently in a child < 15 years who is
20
previously normal (AFP)
Weight loss, swelling of the body (Symmetrical edema) with or without diarrhea
21
(AMN)

Others (please specify): _______________________________________________________________________________

22
_______________________________________________________________________________

1. Keep proper records of daily consultations in register/ logbook

2. Use the daily consultation records to complete Form-1 and submit daily to the Main RHU
_______________________by 4pm until further instructions are given
3. This form is to be filled by BHW/community health workers, midwives, nurses and doctors in temporary
clinics, evacuation centre clinics, BHS & Health Centres
4. HOTLINE (S) for immediate notification of alerts : __________________________________
 Main symptoms, Alert threshold and Recommended Verification Actions

Health Events Possible Diseases Notification Alert threshold Immediate action by Health
staff once alert threshold is
crossed
Cough, colds or sore throat with or Common colds, Pneumonia,
without fever (ARI) Influenza
One case of suspected Report to the MHO/CHO or to
Measles, German measles, measles detected in an evacuation next higher level for
Fever with rash (MEA)
chicken pox center should be considered as the verification/field investigation
beginning of an outbreak & specimen collection
Report to the MHO/CHO or to
Fever with spontaneous bleeding Dengue, blood dyscrasias, One case of acute hemorrhagic
next higher level for
(i.e. nose bleeding, gum bleeding) Nutritional disorders, fever
verification/field investigation
(AHF) Meningococcal disease
& specimen collection
Report to the MHO/CHO or to
One case of suspected leptospirosis next higher level for
Suspected leptospirosis (LEP) Leptospirosis
verification/field investigation
& specimen collection
Report to the MHO/CHO or to
Two suspected cases of next higher level for field
Bacterial meningitis, viral
Suspected meningitis (MEN) meningitis in the same week investigation & immediately
meningitis, encephalitis
collection of CSF to confirm
the cases
Report to the MHO/CHO or to
Viral Hepatitis, A cluster of 3-5 cases of acute
Yellow eyes or skin with or without next higher level for
Leptospirosis, Chemical jaundice syndrome in the same
fever (AJS) verification/field investigation
intoxication reporting unit
& specimen collection
Report to the MHO/CHO or to
Increasing trend for 3 days
Fever with other signs and Malaria, urinary tract next higher level for
associated with or without unusual
symptoms not listed above (FOS) infection, typhoid verification/field investigation
increase of specific mortality
& specimen collection
One death for acute watery diarrhoea
in patients 5 years of age or older Report to the MHO/CHO or to
Loose stools, 3 or more in the past
Cholera, Viral/ bacterial next higher level for
24hrs with or without dehydration
gastroenteritis A cluster of 5 cases in one week of verification/field investigation
(AWD)
watery diarrhoea in patients 5 years of & specimen collection
age or older
A cluster of 3-5 cases of acute bloody Report to the MHO/CHO or to
Loose stools with visible blood Amebiasis, Salmonellosis, diarrhoea in the same evacuation next higher level for
(ABD) Shigellosis center in one week, or the doubling of verification/field investigation
cases in two consecutive weeks & specimen collection
Report to the MHO/CHO or to
next higher level for
Spasms of neck and jaw (lock jaw) verification/field investigation;
Tetanus One case of suspected tetanus
(TET) investigate hygienic practices
used for deliveries in neonatal
tetanus
Report to the MHO/CHO or to
Poliomyelitis, Neurologic One case of acute flaccid
next higher level for
Acute flaccid paralysis (AFP) Disorders, Electrolyte paralysis
verification/field investigation
imbalance, Vit. deficiency
& specimen collection
Weight loss, swelling of the body
(Symmetrical edema) with or without Severe acute malnutrition
diarrhea (AMN)