Acute Flaccid Paralysis EPID Number:

CASE INVESTIGATION FORM IND - ____ -__________ - ______ - ___________

(matches Lab Request Form)
1. Notification / Investigation Information:
Date Case Notified: _____ /_____ / _____ Notified by: _________________________ Title: ______________
Date Case Investigated: _____ / _____ / _____ Investigated by:______________________ Title: DIO/Medical Officer/ Nodal Officer/ SMO/ Other
Date Case Investigated by SMO: _____ / _____ / _____ Name of SMO: __________________________________
Notifying Health Facility:Type : RU/ Informer/ Other Category: VHP/ HP/ LP/ Other Setup: Govt. Allopathic/ Pvt Allopathic/ ISM Pract./ Quack/Others

2. Case Identification: Patient's Name: _________________________________ other given names: ______________________

Sex: _____ Date of birth: ______/ ______ / ______ Age (at onset): years__________ months____________
Father's Name:_________________________________________ Mother's Name:____________________________________
Father's Occupation:_____________________________________ Grand father's Name:________________________________
Address: _____________________________________________ Religion: Muslim / Hindu / Other Caste: ___________________
Landmark: ___________________________________________ Village / Mohalla: ______________________________
HRA: Y / N
Block /Urban area: __________________________ District: _________________________________
Setting: Urban / Rural
State: ______________________________ Tel. ________________________
Child belongs to migratory family/Community : Yes/ No/ Unknown If yes, specify: Slum with migration/ Nomad/ Brick Kiln/ Construction site/ Others (specify): ________

3. Hospitalization: Yes / No Date of Hospitalization:____/____/____

Name of Hospital:________________________________ Diagnosis as per hospital records, if any: ___________________________
4. Immunization History: a. OPV doses received through routine EPI (before onset): ______________
b. OPV doses received through SIAs (before onset): ______________ Total OPV doses (a+b): ______________
Date of last dose of OPV (before onset): _____/ _____/_____ (to be filled in linelist)
Date of last dose of OPV (before stool collection): _____/ _____/_____ (to be filled in LRF)
Number of f-IPV doses received (before onset): _____________ Number of IM-IPV doses received (before onset): _____________
Date of last dose of f-IPV (before onset): _____/ _____/_____ Date of last dose of IM-IPV (before onset): _____/ _____/_____

5. Clinical Symptoms: Date of Paralysis Onset:_____/_____/_____

Number of days from onset to maximum paralysis:_______
Acute paralysis: Yes / No / Unknown Flaccid paralysis (anytime during course of illness)Yes/ No/Unknown
Any Injections during 30 days before paralysis onset: Yes / No / Unknown If Yes, side and site of injection _____________
Fever on day of paralysis onset: Yes / No / Unknown
Ascending paralysis: Yes / No / Unknown Descending paralysis: Yes / No / Unknown

6. Clinical history: (write evolution and progression of illness)

Respiratory involvement: Yes/ No
Bulbar involvement: Yes/ No
Bladder/bowel: Yes/ No
Joint pain/Swelling: Yes/ No
Gait:

7. Travel history: Travel of child within 35 days prior to onset of paralysis (indicate dates and place of travel with arrows on dateline)
Write dates of travel: Day of onset

Write here places visited corresponding to the travel dates District of residence: ____________________________
Requires cross notification? Yes / No
If yes, date of cross notification: Block/ Urban area of residence: ___________________

8. History of contacts with healthcare providers after the date of paralysis onset ( including the notifying health facility):
Name & address of 1 2 3 4
Hospital/ doctor/ quack:

Dates case visited:

Already RU/informer? Yes/No Yes/No Yes/No Yes/No

Did they report this case? Yes/No Yes/No Yes/No Yes/No
Action taken by SMO / Date
of visit by SMO
CIF contains
Pagetwo1 pages, both pages must be filled for all AFP cases
 CIF (Page 2) EPID No.: IND - ____ -__________ - ______ - ___________
9. Clinical examination: Initial case investigation; Date: ____________ 60-day follow-up; Date: ________________
Examined by : __________________________ Examined by : ________________________
Tone: (normal//) UL: Right: LL: Right: UL: Right: LL: Right:
Left: Left: Left: Left:
Power: (Grade 0 to 5)
0 - No Contraction
1 – Flicker of contraction
2 – Active movement with gravity
eliminated

3 – Active Movement against

gravity but no resistance

4 - Active Movement against

resistance
5 – Normal
Reflexes: N/ / / absent/ uncooperative N/ / / absent/ uncooperative N/ / / absent/ uncooperative N/ / / absent/ uncooperative
child child child child

Biceps: Right Left Right Left

Triceps: Right Left Right Left
Supinator: Right Left Right Left
Knee jerk: Right Left Right Left
Ankle jerk: Right Left Right Left
Plantar: Right: flexor / extensor/ Left flexor / extensor/ Right flexor / extensor/ Left: flexor / extensor/
Uncooperative child Uncooperative child Uncooperative child Uncooperative child
Circumference: Mid- Right Left Right Left
arm: Fore-arm: Right Left Right Left
Mid-thigh Right Left Right Left
Mid-calf: Right Left Right Left
Cranial nerves affected Right Left Right Left
Sensation loss: Yes / No / Unknown Asymmetrical paralysis: Yes / No / Unknown Hot AFP case: Yes / No
Site(s) of Paralysis: right arm / left arm / right leg / left leg / neck / bulbar / respiratory muscle / trunk / facial/ other______________

10. Provisional diagnosis:

Guillain-Barre Syndrome / Transverse Myelitis / Traumatic Neuritis / Transient Paralysis / Facial Palsy / other / Unknown If other, specify: _______________
AFP case: Yes / No If No, reason for rejection: Injury / spastic paralysis / onset >6 months / congenital defect / other (specify)____________________
If yes, case selection based on: Flaccid paralysis at the time of investigation / History of flaccid paralysis but no paralysis at the time of investigation / Borderline or ambiguous case

11. Contact stool: Was this case eligible for contact stool collection: Yes / No If yes, date collected: ______ / ______/ ______

12. Stool Specimen Collection:

Date Collected Date Sent Date of Result Condition Laboratory Result (circle)
Stool 1 ___/___/___ ___/___/___ ___/___/___ Good / Poor P1 P2 P3 Wild/Vaccine NPEV Negative
Stool 2 ___/___/___ ___/___/___ ___/___/___ Good / Poor P1 P2 P3 Wild/Vaccine NPEV Negative
If Stool Not Collected in 14 days why? Late Notification/ Late investigation/ Delay in stool collection/ Constipation/ Death/ Lost/ Other
13. Active Case Search and Outbreak Response: Active case search in community done: Yes / No
ORI done: Yes / No If yes, date begun: ___/___/___ Additional AFP case found: Yes / No Number:_________
If no, why?_____________________ Date active case search conducted: ___/___/___
14. 60 Day Follow-up Examination: Not required / Yes / Death / Lost if died, date of death: ____/____/____
Date of follow-up: ____/____/____ Residual weakness present: Yes/No cause of death: _________________________
Site of weakness: right arm / left arm / right leg / left leg / neck / bulbar / respiratory muscle / trunk / facial/other _____________________
15. Final Classification: Confirmed Polio / Compatible / Discarded
If compatible, why? _____________________________________________________________________________
If discarded, what was the final diagnosis:
Guillain-Barre Syndrome / Transverse Myelitis / Traumatic Neuritis / Transient Paralysis / Facial Palsy / other / Unknown If other, specify: _________________
Use extra sheet of paper to write additional information, if any.