Scribd
Upload
54 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
54 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
You are on page 1/ 1

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.

You might also like