Version 2022

Epidemic-prone Disease Case Report Form

Case Surveillance
Typhoid and Paratyphoid Fever (ICD 10 Code: A01.0, A01.1-
A01.4)
Region: Province: Municipality/City:
Name of DRU: Type: ◻RHU ◻CHO/MHO/PHO ◻Gov’t Hospital ◻Private
Hospital Address: ◻Clinic ◻Gov’t Laboratory ◻Private Laboratory
◻Airport/Seaport Name of Interviewer: Type of site: ◻Sentinel ◻Non-sentinel

Indige- Con- Date of Place of Date Admitted/ Date onset of

Patient Civil Complete Current Complete Permanent Admitted?
Patient’s Full Name Age Sex Date of Birth nous sulted FIRST Consultation Seen/ illness (FIRST
No. Status Address Address People ? consultation Consulted symptoms)

/ / / / / / / /

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/ / / / / / / /

Age: Indicate
D - days S-Single
Response M-Married Specify House # Street/ Specify House # Street/ Please
M - months
Codes / Indicate Last name, First name, Sep- Purok/Subdivision, Ba- Purok/Subdivision, specify Y - Yes Name of Y - Yes
Yr. - years mm/dd/yyyy mm/dd/yyyy mm/dd/yyyy mm/dd/yyyy
Instruc- Middle name Separated rangay, Municipality/ Barangay, what N- No Facility N- No
Sex: W-
tions City, Province, Region Municipality/ City, tribe
F - Female Widowed Province, Region
M - Male
Case Definition:
 Confirmed case: A suspected or probable case that is laboratory confirmed.
 Suspected case: A person with an illness characterized by insidious onset of sustained fever, headache,
malaise, anorexia, relative bradycardia, constipation or diarrhea, and non-productive cough for 5 days or
more. Laboratory Confirmation:
Probable case:
  Laboratory confirmation by culture or molecular methods of Salmonella typhi or detection of Salmonella
typhi or Sal-
 A suspected case that is positive in Typhoid Rapid Diagnostic Test, or monella paratyphi DNA from a normally sterile site.
 A suspected case that is epidemiologically linked to a confirmed case in an outbreak.
Deliberately providing false or misleading, personal information on the part of the patient, or the next of kin in case of patient’s incapacity, may constitute non-cooperation punishable under the Republic Act. No. 11332
 Version 2022
Epidemic-prone Disease Case Report Form
Case Surveillance
Typhoid and Paratyphoid Fever (ICD 10 Code: A01.0, A01.1-
A01.4)
Date of Specimen Laboratory Laboratory Case
Patient No. Patient’s Full Name Age Sex Date of Birth Organism Outcome Date of death
Collected Test Done Result Classification

/ / / / / /

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/ / / / / /

/ / / / / /

Widal’s Test
Age: Indicate Typhi Dot
D - days Tubex
P– Positive Salmonella typhi
Response M - months Blood Culture S—Suspect
Indicate Last name, First name, Middle N– Negative Salmonella paratyphi A-
Codes / Instruc- Yr. - years mm/dd/yyyy mm/dd/yyyy Stool Culture P—Probable mm/dd/yyyy
name ND– Not done U– Unknown Alive D
tions Sex: Serotyping/ C– Confirmed
F - Female U- Unknown NA– Not applicable - Died
Serogrouping
M - Male ND– Not done
U– Unknown

Case Definition:
 Suspected case: A person with an illness characterized by insidious onset of sustained fever, headache,  Confirmed case: A suspected or probable case that is laboratory confirmed.
malaise, anorexia, relative bradycardia, constipation or diarrhea, and non-productive cough for 5 days or
more. Laboratory Confirmation:
 Probable case:
 A suspected case that is positive in Typhoid Rapid Diagnostic Test, or  Laboratory confirmation by culture or molecular methods of Salmonella typhi or detection of Salmonella
typhi or Sal-
monella paratyphi DNA from a normally sterile site.
 A suspected case that is epidemiologically linked to a confirmed case in an outbreak.

Deliberately providing false or misleading, personal information on the part of the patient, or the next of kin in case of patient’s incapacity, may constitute non-cooperation punishable under the Republic Act. No. 11332