Version 2022

Case Report Form

Epidemic-prone Disease Acute Bloody Diarrhea
Case Surveillance (ICD 11 Code: A09.0)

Region of DRU: ______________ Province of DRU: _______________ Barangay of DRU__________ Site : Sentinel Site Non– Sentinel Site
Name of DRU: ________________________________________________________________ Type: RHU/CHO Gov’t Hospital Private Hospital Clinic
Name of Interviewer: ________________________ Contact Number of Interviewer: _____________ Private Laboratory Public Laboratory Seaport/ Airport Other: __________

Indige- Con- Place of Date onset of

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

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Age: Indicate
D - days Specify House #
Specify House # Please
Response M - months Street / Purok/Subdivision,
Indicate Last name, First Street / Purok/Subdivision, specify Y - Yes Name of Y - Yes
Codes / Yr. - years mm/dd/yyyy Barangay, Municipality/ mm/dd/yyyy mm/dd/yyyy mm/dd/yyyy
name, Middle name Barangay, Municipality/ City, what N- No Facility N- No
Instructions Sex: City,
Province, Region tribe
F - Female Province, Region
M - Male
Case Definition:
Suspected case: A person with acute (< 14 days) diarrhea with visible blood in the stool.

Confirmed Case: Any suspected case positive for bacterial or parasitic pathogens (i.e Shigella dysenteriae type 1, Entamoeba histolytica or Escherichia coli) through bacterial culture or any molecular diagnostic test.

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

Case Report Form

Epidemic-prone Disease Acute Bloody Diarrhea
Case Surveillance
(ICD 11 Code: A09.0)

Date of Specimen Laboratory Test Organism Identified Case

Patient No. Patient’s Full Name Age Sex Date of Birth Laboratory Results (For positive Outcome Date of Death
Collected Done laboratory results only)
Classification

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E.Coli 0157;07
Please specify (EHEC)
Age: Indicate
laboratory test done Shigella spp.
D - days  P - Positive
Campylobacter
Response Indicate Last name, M - months  N - Negative
 Culture spp. S—Suspect A - Alive
Codes / First name, Middle Yr. - years mm/dd/yyyy mm/dd/yyyy  PR— Pending mm/dd/yyyy
 Serogrouping/ Salmonella spp. C– Confirmed D - Died
Instructions name Sex: Result
Serotyping Other bacterial or
F - Female  ND- Not done
 Not done parasitic pathogens
M - Male  UNK- Unknown
 Unknown NA- Not applicable
UNK- Unknown

Case Definition:
Suspected case: A person with acute (<14 days) diarrhea with visible blood in the stool.
Confirmed Case: Any suspected case positive for bacterial or parasitic pathogens (i.e Shigella dysenteriae type 1, Entamoeba histolytica or Escherichia coli) through bacterial culture or any molecular diagnostic test.

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