Daily Report from Private Hospitals and Registered Medical Practitioners of Jalna District
This form should be filled by all Private practitioners in Jalna District about status of their hospitals clinics everyday.
They should fill data about CASES OF INFLUENZA LIKE ILLNESS (ILI) and SARI (SEVERE ACUTE RESPIRATORY ILLNESSES) If you observe any of the Symptoms as listed below, Send details of the patient.
If more than one patient, fill up form again, multiple submission is allowed.
If you find unusual symptoms like Fever/Chills, Sore throat,
With implementation of Disaster Management Act 2005 and epidemic act in Jalna District for control of COVID 19 its mandatory for all RMP IN Jalna District to report cases of ILI AND SARI.
Submit nil report, if you do not find any patient with symptoms, in this case , name of the patient be filled as NIL and mobile number as 9999999999


You have to fill up this form on daily basis upto 4.00pm without fail.
Name & Address of Clinic/Hospital *
Taluka *
Name of Doctor *
Mobile No. of Doctor *
Name of Patient with Influenza like illness (ILI) or SARI Symptoms *
Age *
Patient Contact No. *
Address Of Patient
Village Name *
Taluka Name *
Whether suffering from any of following conditions: *
Required
Symptoms Observed ( Multiple selection Allowed) *
Required
Dignosis *
If Other Specify
Whether Admitted *
Whether Reffered *
If Yes Reffered Hopital Details-
Any Travels History *
Submit
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