Malaria Form – Fill Out and Use This PDF

Malaria Case Surveillance Report form (OMB 0920-0009)

This form is used for reporting smear-confirmed cases of malaria to the National Malaria Surveillance System. Completed forms should be sent to the attention of malaria surveillance at the address at the top of the form.

To complete the form:

The form is largely self-explanatory; however, below are explanatory notes to assist you in completing the form.

PART I

State Case No: Space provided for states that assign their own case numbers.

CSID No: Please leave blank (for CDC use only).

Case No: Please leave blank (for CDC use only).

County: Space provided for states that classify cases by the reporting county.

Patient name:

Please provide, if allowed by local patient confidentiality regulations. No personal identifiers are used in the reporting of the surveillance summary. Because CDC often receives more than one report on a malaria case, names are useful to remove duplicate reports. If names are not permissible, then the patient’s initials or birth date would be helpful.

Date of birth:

Will help identify duplicate cases if patient name or other identifiers have not been provided.

Is patient pregnant?

An attack of malaria in a pregnant woman may be more severe than in a non-pregnant woman. In addition, treatment recommendations may be different.

Positive Lab results:

Please report all smear-confirmed, PCR-positive and RDT-positive cases, even if other surveillance information is not available.

Specimens being sent to CDC?

This information allows CDC to coordinate its laboratory results with the surveillance form.

Country:

Please include all countries of travel or residence outside the United States. If the specific countries are unknown, then the region of the world may be used, e.g. southern Africa, Central America.

Did patient reside in U.S. prior to most recent travel?

Yes, for ﾕ12 months: Mark yes if the patient resided in the U.S. before travel outside of the U.S.

No, (specify country): Mark no if the patient did not reside in the U.S. before traveling to the U.S., and then specify the country of residence.

Unknown: Mark unknown if this information is not available.

Principal reason for travel from/to U.S. for most recent trip:

These categories apply to U.S. residents traveling overseas and to non-U.S. residents arriving in the U.S. Tourism: Check this option if the travel was primarily for pleasure.

Military: Check this option if the traveler was either in the U.S. military and stationed overseas, or a member of foreign military while traveling to the U.S.

Business: Check this option if travel was primarily business related, e.g. oil companies, archeology.

Peace Corps: Check this option if the traveler was a member of the Peace Corps while overseas. Visiting friends/relatives:

Check this option if the traveler can be categorized as a person who visited friends and relatives (VFR). A VFR is an immigrant, ethnically and racially distinct from the majority population of the country of residence (a higher-income country), who returns to his or her homeland (lower-income country) to visit friends or relatives. Included in the VFR category are family members such as the spouse or children, who were born in the country of residence.

Airline/ship crew: Check this option if the person traveled overseas as a part of a flight or ship’s crew.

Missionary or dependent: Check this option if the traveler or a family member was traveling for missionary purposes.

Refugee/immigrant: Check this option if the traveler arrived in the U.S. with the intention to establish residency in this country.

Student/teacher: Check this option if the travel was primarily for educational purposes.

Was malaria chemoprophylaxis taken?

This information captures whether an antimalarial drug was taken for prevention during travel. (Do not include treatment drugs used for this attack of malaria.) The questions on chemoprophylaxis are useful for determining adherence and the reasons for non-adherence to CDC antimalarial drug recommendations.

If yes, which drugs were taken?

Please check all drugs and drug combinations that apply.

History of malaria in last 12 months (prior to this report):

Check “Yes” if malaria was diagnosed either overseas or in the U.S. in the past year.

Blood transfusion/organ transplant within last 12 months?

Information about previous transfusions is used to identify possible transfusion-induced malaria, especially among patients with no history of foreign travel. Do not check “Yes” if the transfusion was used to treat this attack of malaria. That information should be noted under “Therapy for this attack.”

PART II

Part II of the Malaria Case Surveillance form will capture data on treatment regimen and treatment outcome. This section of the surveillance form is not obligatory; however, it is requested that Part II is sent if information is available. This section is to be completed 4 weeks after treatment.

Did all signs or symptoms of malaria resolve without any additional malaria treatment within 7 days after the start of treatment?

This information captures whether the malaria treatment worked in clearing up all of the patient’s symptoms related to the malaria infection in the 7 days after starting treatment.

If yes, did the patient experience a reoccurrence of signs or symptoms of malaria during the 4 weeks after starting treatment?

This information captures whether signs and symptoms of the malaria infection returned after initial treatment.

Did the patient experience any adverse events within 4 weeks after receiving the malaria treatment?

Adverse events are any unintended sign, symptom, reaction, or disease that occurs during or after the use of a treatment or drug, but is not necessarily caused by it.

If Yes:

Event description:

Describe the adverse event.

Relationship to treatment suspected:

Was the adverse event related to the treatment given? Time to onset since treatment start:

How long after starting the initial treatment did the adverse event occur?

Fatal?

Did the adverse event cause the patient to die?

Life-Threatening?

Did the adverse event cause a life-threatening situation to the patient?

Other serious situation?

Excluding death or a life-threatening situation, did the adverse event cause a severe situation for the patient (e.g.,. persistent disability/incapacity, congenital anomaly/birth defect, or prolongation of hospitalization)

The back of the Malaria Case Surveillance form contains useful telephone numbers for contacting the Malaria Branch for treatment and prevention information.

If you have any questions or concerns about completing this form, please call CDC, Malaria Branch at 770-488-7788 or 855-856-4713 (9 am - 5 pm, EST).