EPIDEMIOLOGICAL INVESTIGATION OF VBD / ZOONOTIC DISEASES /

ISOLATED CASES / OUTBREAK -

Final Report

District: Date:

1. Affected Area Details:

Sl.No. Name of the

PHC HSC Village Pop. of village
Block

2. Surrounding / Neighboring Area Details:

Sl.No. Name of Pop. of

PHC HSC Village
the Block village
3. Daily Report

Houses Containers Breteau

Date of Name of Index
No. No.
Survey Village Positive Index Positive Index
checked checked

Total

4. Medical Team Details:

Total Team 1 Team 2 Team 3

Date No.of Area No. No. Area No.
Area covered
Teams covered treated treated covered treated

Total
 5. Water Chlorination: Total No.of

a) OHT:
b) Street Pipe:
c) House Pipe:
OHT House Pipe Street Pipe
Village
Sl.No. Date No. Nil No. Nil No. Nil
Name
Checked Chlorine Checked Chlorine Checked Chlorine

Total

6. Antilarval Measures: No.of Teams formed:

No.of Team 1 No.of Team 2

Area Area
Date houses Sources houses Sources
Covered Covered
covered Identified reduced treated covered Identified reduced treated

Total

7. Anti Adult Measures Adulticide Used:

No.of houses
Date Area Covered
Covered

Total
 Affected HSC:

Village A Village B Village B

Blood Serum Blood Serum Blood Serum

Total Total Total
Date of Smear Sample Smear Sample Smear Sample
Day
Survey
Result

Result

Result

Result

Result

Result
Death

Death

Death
Fever

Fever

Fever
Coll.

Coll.

Coll.

Coll.

Coll.

Coll.
Total

LINE LIST OF FEVER CASES ( ANNEXURE B )

NAME OF THE VILLAGE :

Age and Sex

Date of Blood Smear Serum Sample

Door No.
Signs and Onset
S.No Name, and Street
Symptoms fever /
Name Date of Date of
symptoms Result Result
Collection Collection
 AGE GROUP AND SEX DISTRIBUTION OF CASES ( ANNEXURE C )

Village A Village B Village C

Age Group
Total cases Total cases Total cases
Male Female Male Female Male Female
upto upto upto

Total

No.of Blood
Serum Sample Duration of Outbreak
Sample
No.of
Total
Fever Total
Deaths First Reporting Total
Cases Coll. Result Sample Result Last Case
Case Date Period
Coll.

Deputy Director of Health Services,

(HUD)