Communicable Disease Control in Emergencies - A Field Manual (WHO - OMS, 2003, 223 p.): ANNEX 2: SAMPLE HEALTH SURVEY FORMS

Communicable Disease Control in Emergencies - A Field Manual (WHO - OMS, 2003, 223 p.)

		(introduction...)
		ACKNOWLEDGEMENTS
		INTRODUCTION
		CHAPTER 1: RAPID ASSESSMENT
		CHAPTER 2: PREVENTION
		CHAPTER 3: SURVEILLANCE
		CHAPTER 4: OUTBREAK CONTROL
		CHAPTER 5: DISEASE PREVENTION AND CONTROL
		ANNEX 1: WHO REFERENCE VALUES FOR EMERGENCIES
		ANNEX 2: SAMPLE HEALTH SURVEY FORMS
		ANNEX 3: NCHS/WHO NORMALIZED REFERENCE VALUES FOR WEIGHT FOR HEIGHT BY SEX
		ANNEX 4: SAMPLE WEEKLY SURVEILLANCE FORMS
		ANNEX 5: RECOMMENDED CASE DEFINITIONS
		ANNEX 6: OUTBREAK INVESTIGATION FORMS
		ANNEX 7: ORGANIZATION OF AN ISOLATION CENTRE
		ANNEX 8: BASIC LABORATORY SERVICES
		ANNEX 9: LABORATORY INVESTIGATION KIT
		ANNEX 10: TREATMENT GUIDELINES
		ANNEX 11: MANAGEMENT OF THE CHILD WITH COUGH OR DIFFICULTY IN BREATHING6
		ANNEX 12: ASSESSMENT AND TREATMENT OF DIARRHOEA
		ANNEX 13: FLOW CHARTS FOR SYNDROMIC MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS
		ANNEX 14: SAMPLE HEALTH CARD
		ANNEX 15: LIST OF WHO GUIDELINES ON COMMUNICABLE DISEASES
		ANNEX 16: LIST OF PUBLISHERS
		ANNEX 17: GENERAL REFERENCES

ANNEX 2: SAMPLE HEALTH SURVEY FORMS

1. Household Member Information List

Main respondent: _ Wife of head of household and mother of the children (if there are any children)
_ other (specify): _________________________________________

Head of the household: _ male _ female / _ refugee status _ no refugee status / _ self employed _ employed _ has part time job _ does not have job

TABLE 1: List below all individuals who since (insert date of significant event), are or have been living for at least one month in the household, including those who died or are missing

Household member number	Main respondent (x)	Head of household (x)	Age in years (if 2 years or older)	Age in months (if under 2 years)	Sex (m / f)	Present at interview? (yes / no)	Household member is... 1. Core family 2. Extended family 3. Other (specify)	Household member is today... 1. Alive, always lived in this household 2. Alive, moved in, still present 3. Alive, moved out 4. Alive in prison 5. Died, had always lived in this household 6. Died, moved in/out 7. Missing/Unknown	If dead or missing, since when? (date: dd / mm)	If dead, why: 1. Disease 2. During / right after delivery 3. Road accident 4. Domestic accident 5. Work accident 6. Conflict casualty 7. Suicide
1									/
2									/
3									/
4									/
5									/
6									/
7									/
8									/
9									/
10									/
11									/
12									/

2. Communicable Diseases in Under Fives (Fever, ALRI, Diarrhoea)

In the last 2 weeks, has any child under 5 years of age in the household suffered from a cough or cold, diarrhoea or any fever?

_ yes _ no

IF YES, complete table 2
IF NO, cross out table 2

TABLE 2: Fever, ALRI, Diarrhoea

Household Number	Number of Episodes of...				Did you access medical assistance during any episode? (yes / no)	If accessed medical assistance, at what level? 1. Traditional Healer 2. Community Health Worker 3. Health Centre 4. Hospital (Mark option with cross)	Did you receive medications? (yes / no)	If received medications, what were they? 1. antibiotics 2. ORS 3. Other/Unknown (Mark option with cross)
	Fever	Fever without cough, cold, diarrhoea	Cough or cold	Diarrhoea
1						1. ____ 2.____ 3.____ 4.____		1.____ 2.____ 3.____
2						1. ____ 2.____ 3.____ 4.____		1.____ 2.____ 3.____
3						1. ____ 2.____ 3.____ 4.____		1.____ 2.____ 3.____
4						1. ____ 2.____ 3.____ 4.____		1. ____2.____ 3.____
5						1. ____ 2.____ 3.____ 4.____		1.____ 2.____ 3.____
6						1. ____ 2.____ 3.____ 4.____		1.____ 2.____ 3.____
7						1. ____ 2.____ 3.____ 4.____		1.____ 2.____ 3.____
8						1. ____ 2.____ 3.____ 4.____		1.____ 2.____ 3.____
9						1. ____ 2.____ 3.____ 4.____		1.____ 2.____ 3.____
10						1. ____ 2.____ 3.____ 4.____		1.____ 2.____ 3.____
11						1. ____ 2.____ 3.____ 4.____		1.____ 2.____ 3.____
12						1. ____ 2.____ 3.____ 4.____		1.____ 2.____ 3.____

3. Non Communicable Diseases

Since (insert date), ...

... has there been anybody in the household with hypertension (diagnosed by a physician)?

_ yes _ no

... anyone in the household with diabetes (diagnosed by a physician)?

_ yes _ no

... anyone in the household with heart disease (diagnosed by a physician)?

_ yes _ no

... anyone in the household with kidney failure (diagnosed by a physician)?

_ yes _ no

If YES: complete table 3 (one line per person and disease, same person can have more than one disease)
If NO: cross out table 3

TABLE 3: Hypertension, Diabetes Mellitus, Heart Disease and Kidney Failure

Household member No.	Disease 1.Hypertension 2.Diabetes 3.Heart Disease 4.Kidney Failure	Information source: 1.Health card 2.Self reported 3.Household member (other than the patient)	Has been or is under regular medical follow-up? (yes/no)	Any scheduled appointment missed (incl. dialysis)? (yes/no)		Has been / is on regular drug treatment? (yes/no)	Interruption in drug treatment of any length (for dialysis: more than a week)? (yes/no)		As of today, is he/she: 1.Alive, home 2.Alive, in hospital 3.Alive,elsewhere 4.Died, at home 5.Died, in hospital 6.Died, elsewhere	If yes for any missed or postponed appointments or interruption of drug treatment or dialysis at any time, rank up to 3 reasons FLASH CARD
	(one line per person and disease)	(list all sources below)		In the last month	Since (date)		In the last month	Since (date)
1										1.______ 2. ______ 3. ______
2										1.______ 2. ______ 3. ______
3										1.______ 2. ______ 3. ______
4										1.______ 2. ______ 3. ______
5										1.______ 2. ______ 3. ______
6										1.______ 2. ______ 3. ______

4. Maternal Health

Since (date), has there anybody been or become pregnant?

_ yes _ no

IF YES, complete table 4
IF NO, cross out table 4

TABLE 4: Antenatal care

Household member No.

Guess how many months since day conceived

Information source:
1. Antenatal card
2. Self reported
3. Household member other than the one pregnant

list all sources below

Which facility gone to have ante-natal care?
1. General
2. Private

Anti-tetanus vaccination given? + HB + urine check
1. NO
2. YES, verified by card
3. YES, reported orally

How many times gone for antenatal care?

Write "zero" if never gone

Asked to attend more than one check per month?

(yes/no)

If yes, always gone?

(yes/no)

If no,

rank up to

3 reasons

FLASH CARD

Admitted to hospital during pregnancy to ensure adequate follow-up?

(yes/no)

Any medicine prescribed during pregnancy?

(yes/no)

If yes, was / is it possible to complete the treatment?

(yes/no)

If no,

rank up to

3 reasons

FLASH CARD

1._________ 2._________ 3._________

Since (date)... has any woman in the household given birth or lost a child during pregnancy?

_ yes _ no

IF YES, complete table 5
IF NO, cross out table 5

TABLE 5: Delivery / Stillbirth / Abortion / Post-natal Care

Household member No.	Baby born: 1. Alive, weight more than 2500g 2. Alive, weight less than 2500g 3. Alive, weight not known 4. Dead, born after 28^th week 5. Baby lost before end of 28^thweek	Date conceived (dd / mm) (if not known exactly, make best guess)	Date of delivery or loss of baby (dd / mm) (if not known exactly, make best guess)	Baby born through: 1.Normal (vaginal) delivery or abort 2.Caesarean section	Where did the delivery (or loss of baby) take place? 1. Home 2. MCH 3. PHC 4. Hospital 5. On the way to hospital 6. Other (specify)	If at MCH, PHC or Hospital, how long did it take to get there? 1. 1 hour or less 2. 1-2 hours 3. 2-4 hours 4. more than 4 hours	If home delivery was it own choice? (yes/no)	If no, rank up to 3 reasons FLASH CARD	If home delivery, assisted by whom? 1. Nobody 2. Family/friend 3. Nurse 4. Midwife 5. Doctor 6. TBA	Gone for any post-natal care visit? (yes/no)
1								1___ 2___ 3___
2								1___ 2___ 3___
3								1___ 2___ 3___
4								1___ 2___ 3___
5								1___ 2___ 3___
6								1___ 2___ 3___

5. SAMPLE DATA COLLECTION FORM FOR RAPID ASSESSMENT SURVEY

1. Date of study (dd/mm/yy)					____/____/______
2. Section number					_______________
3. Name of camp/site					_______________
4. Date of arrival in site (dd/mm/yy)					____/____/______
5. Total number of people in household:					_______________
6. Total number of children under 5 years:					_______________

Nutritional and vaccination coverage information in child < 5 years:
7. Sex (1=M, 2=F):					1	2
8. Age (6-59 months):					___________ months
9. Weight (in kg, precision to 100g):					___________ kg
10. Length/ Height (in cm, precision to 0.5 cm):					___________ cm
11. Presence of bilateral pitting oedema:					Y	N
12. MUAC (Mean Upper Arm Circumference):					___________ mm
13. Date of measles vaccination (card):					____/____/______
[14. OPV (all 4 doses at appropriate time intervals):					Y	N]
[15. DPT (all 4 doses at appropriate time intervals) or DT:					Y	N]

Retrospective Mortality:
16. Total number of deaths since (insert date of significant event)					_______________

	Death 1.	Age_______Month______Cause________
	Death 2.	Age_______Month______Cause________
	Death 3.	Age_______Month______Cause________
	Death 4.	Age_______Month______Cause________
	Codes:
	Age: 0 = 0-11months; 1= 12months-23 months; 2 = 2 years; 3 = 3 years etc
	Month: example: 11 = Nov 1999; 12 = Dec 1999; 1= Jan 2000; 2 = Feb 2000
	Cause: example: 1= diarrhoea; 2=fever; 3=cough; 4=measles; 5=other

Refugee Environment:
17. Type of habitation (circle):			1	2	3		4
1=plastique roof only; 2=simple hut; 3=tent; 4=other

18. Latrines (circle):			1	2	3		4
1=collective latrines; 2=trench; 3=defecation field; 4=no specific area

19. Water containers (at least one 20 L per household):			Y	N
20. Blankets (at least one per person):			Y	N

Morbidity data:
In the last 14 days, has any child under 5 years suffered from:
21. Fever			Y	N
22. Fever without cough, cold, diarrhoea			Y	N
23. Cough or cold			Y	N
24. Diarrhoea (3 liquid stools in 24 hours)			Y	N