ABCDEFGHIJKLMNOPQRSTUVWXYZ
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Acute Flaccid ParalysisEPID Number:
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CASE INVESTIGATION FORM
IND - ____ -__________ - ______ - ___________
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(matches Lab Request Form)
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1. Notification / Investigation Information:
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Date Case Notified: _____ /_____ / _____
Notified by: _________________________
Title: ______________
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Date Case Investigated: _____ / _____ / _____
Investigated by:______________________
Title: DIO/Medical Officer/ Nodal Officer/ SMO/ Other
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Date Case verified by DIO/SMO: _____ / _____ / _____
Name of DIO/SMO: __________________________________
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Notifying Health Facility:Type : RU/ Informer/ Other Category: VHP/ HP/ LP/ Other Setup: Govt. Allopathic/ Pvt Allopathic/ ISM Pract./ Quack/Others
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2. Case Identification:
Patient's Name: _________________________________
other given names: ______________________
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Sex: _____
Date of birth: ______/ ______ / ______
Age (at onset): years__________ months____________
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Father's Name:_________________________________________
Mother's Name:____________________________________
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Father's Occupation:_____________________________________
Grand father's Name:________________________________
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Address: _____________________________________________
Religion: Muslim / Hindu / Other
Caste: ___________________
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Landmark: ___________________________________________
Village / Mohalla: ______________________________
HRA: Y / N
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Panchayat/Ward No: __________________________
Pin Code: _________________
ID No:( )_______________________
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Block /Urban area: __________________________
District: _________________________________
Setting: Urban / Rural
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State: ______________________________
Tel. ________________________
Alternate tel. _________________
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Child belongs to migratory family/Community : Yes/ No/ Unknown
If yes, specify: Slum with migration/ Nomad/ Brick Kiln/ Construction site/ Others (specify): ________
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3. Hospitalization:Yes / No
Date of Hospitalization:____/____/____
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Name of Hospital:________________________________
Diagnosis as per hospital records, if any: ___________________________
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4. Immunization History:
a. OPV doses received through routine EPI (before onset): ______________
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b. OPV doses received through SIAs (before onset): ______________
Total OPV doses (a+b): ______________
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Date of last dose of OPV (before onset): _____/ _____/_____ (to be filled in linelist)
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Date of last dose of OPV (before stool collection): _____/ _____/_____ (to be filled in LRF)
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Number of f-IPV doses received (before onset): _____________
Number of IM-IPV doses received (before onset): _____________
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Date of last dose of f-IPV (before onset): _____/ _____/_____
Date of last dose of IM-IPV (before onset): _____/ _____/_____
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5. Clinical Symptoms:
Date of Paralysis Onset:_____/_____/_____
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Number of days from onset to maximum paralysis:_______
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Acute paralysis: Yes / No / Unknown
Flaccid paralysis (anytime during course of illness)Yes/ No/Unknown
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Any Injections during 30 days before paralysis onset: Yes / No / Unknown
If Yes, side and site of injection _____________
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Fever on day of paralysis onset: Yes / No / Unknown
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Ascending paralysis: Yes / No / Unknown
Descending paralysis: Yes / No / Unknown
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6. Clinical history:
(write evolution and progression of illness)
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Respiratory involvement: Yes/ No
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Bulbar involvement: Yes/ No
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Bladder/bowel: Yes/ No
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Joint pain/Swelling: Yes/ No
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Gait:
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7. Travel history:
Travel of child within 35 days prior to onset of paralysis (indicate dates and place of travel with arrows on dateline)
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Write dates of travel:Day of onset
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Write here places visited corresponding to the travel dates
District of residence: ____________________________
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Requires cross notification? Yes / No
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If yes, date of cross notification:
Block/ Urban area of residence: ___________________
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8. History of contacts with healthcare providers after the date of paralysis onset ( including the notifying health facility):
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Name, mobile number and address of Hospital/ doctor/ quack:1234
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Dates case visited:
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Already RU/informer?Yes/NoYes/NoYes/NoYes/No
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Did they report this case?Yes/NoYes/NoYes/NoYes/No
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Action taken by SMO / Date of visit by SMO
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CIF contains two pages, both pages must be filled for all AFP cases
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Identification Number Code: 1 - Aadhaar card, 2 - Voter Card, 3. PAN, 4. Passport, 5. Driving licence number, 6. National Health ID, 7. State Health ID, 8. Other
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