Diphtheria - Case Investigation Form (CIF)
EPID No: PAK/______/______/_____/Msl/__________ Cross Notified
( PAK/Province ID/District ID/Year/Per/Case Serial # # # #) Yes ⎕ No ⎕
Part-1: For use by reporting health facility and/ or investigation team and District Health Office
Reported by Passive Surveillance ⎕ Active Surveillance ⎕ Active Search ⎕
Case Report
Reported from Public Health Facility ⎕ Community ⎕ Private Sector ⎕
Name of Reporting Site ________________________ Reporting Person ______________________ Designation ________
Union Council _______________Tehsil/Town/Taluka __________________District ________________ Province ________
Patient's Name ______________________________ Father's Name _______________________________ Sex Male ⎕
Patient Details
Date of Birth ____/_____/_______ Age: ____in months. Contact No. 1 ___________________ Contact No. 2 _________
Complete Address of Patient: Village/Street/Mohalla ________________________________________________________
Nearby landmark _____________________Union Council ____________________ Tehsil/Town/Taluka______________
District _________________________ Province/Administrative Area___________________ Nationality _____________
Date of onset (illness) : ____ /____/_______ Date of Notification: ___/___/______ Date of Investigation: ___/___/__
Sign & Stridor Symptoms: ⎕ Fever ⎕ Swollen neck ⎕ Sore throat ⎕ Shortness of breath ⎕ Difficulty swallow
Fatigue ⎕ Malaise ⎕ Change in voice ⎕ Pseudo membrane ⎕ Other ______________________________
Complications: ⎕ Airway obstruction ⎕ Myocarditis ⎕ Peripheral neuritis ⎕ Kidney failure ⎕ Other ______________
Clinical Findings
DPT containing vaccine (Penta, DTP, Td) received in Routine EPI: 0 ⎕ 1 ⎕ 2 ⎕ 3 ⎕ Booster-1 ⎕ Booster-2 ⎕ Un
Hospitalized due to current illness: Yes ⎕ No ⎕,
Date of last DPT containing vaccination: ___/___/_______ Verified by: Recall ⎕ EPI card ⎕ If Zero dose (reaso
⎕ Unaware ⎕ Not Eligible ⎕ Missed ⎕ Other________
Number of additional DPT containing vaccine doses received during Campaign/ORIs/mop-up: _____________
Treatment: Antibiotics Yes ⎕ No ⎕ Specify: _______________ Date of start of Antibiotics : ____ / _____/ _____
Diphtheria Antitoxin (DAT) given: Yes ⎕ No ⎕; if Yes, Date of Antitoxin: ____ / _____/ _______
Sample collected: Yes ⎕ No ⎕ , If Yes Type of sample (tick) Throat ⎕ Nasopharyngeal
Sample
Date of Sample Collection ____ / _____/ _______ ____ / _____/ _____
Date of Sample sent to Lab ____ / _____/ _______ ____ / _____/ _____
Did the case come in contact with anyone with similar symptoms in 1-10 days before onset. Yes ⎕ No ⎕; if Yes,
Who (Person) ___________________________________ Where (Place)________________________________________
Did anyone come in contact with the case, within 10 days after onset of the illness Yes ⎕ No ⎕; if Yes
Who (Person) ___________________________________ Where (Place)________________________________________
Source
Enrolled at School or Madarsa: Yes ⎕ No ⎕ ; If yes, Name of School/Madarsa: _____________________________
Visited a HF in the 10 days before symptom onset: Yes ⎕ No ⎕ ; If Yes name of HF: ____________________________
Travel history in the past 10 days before onset of illness: Yes ⎕ No ⎕ ; If Yes, Address __________________________
UC ________________ Tehsil ________________ District ______________________ Province ___________________
Investigated by (Name) ___________________ Designation_________________ Signature______________ Contact# ___
Part 2 – To be used by receiving laboratory Lab ID : ___________
Test Conducted by (Name) _________________ Designation_______________ Signature______________ Date ____ / __
Throat ⎕ Nasopharyng
Date of Specimen Received ____ / _____/ _______ ____ / _____/
Cold chain Yes ⎕ No ⎕ Yes ⎕ N
LAB
Sample Condition [If inadequate (Reason/s)] Adequate ⎕ Inadequate ⎕ Adequate ⎕ Ina
Lab Results Received at District on Dated ____ / _____/ _______ ____ / _____/
Lab Results shared Type of Test Done
Reporting HCPN ⎕ Parents ⎕ Test Results
Report Sent by (Name) __________________ Designation_______________ Signature______________ Date ____ / ___
Part-3: Final Classification
Lab confirmed Diphtheria ⎕ Epi linked Diphtheria ⎕ Clinical Compatible Diphtheria ⎕ Discarded ⎕
Other diagnosis______________________________ Follow up Conducted Yes ⎕ No ⎕
Outcome : Recovered ⎕ Sick ⎕ Lost to follow up ⎕ Died ⎕ If died Date ____ / _____/ _______
This case is Sporadic ⎕ Part of Outbreak ⎕
Classified by (Name) __________________ Designation_______________ Signature______________ Date ____ / ____
Note: Please send the 1st copy of this CIF to laboratory with specimen, 2nd copy to be sent to CEO/DHO (Health) office and 3rd copy to be kept in reporting health facility.
CEO/DHO office must ensure to send filled scan copy to provincial EPI Cell. 2. All fields are compulsory/mandatory to be filled. 3. Write Form No. on Sample taken
Diphtheria V.1.0 form developed in July 2024
Diphtheria - Case Investigation Form (CIF)
Comments:
Note: Please send the 1st copy of this CIF to laboratory with specimen, 2nd copy to be sent to CEO/DHO (Health) office and 3rd copy to be kept in reporting health facility.
CEO/DHO office must ensure to send filled scan copy to provincial EPI Cell. 2. All fields are compulsory/mandatory to be filled. 3. Write Form No. on Sample taken
Diphtheria V.1.0 form developed in July 2024
