DENGUE NS1 RDT

MONTHLY CONSOLIDATION REPORT FORM

(Please tick reporting level)

Region: __________ Province/City: __________ Municipality: ___________ Barangay: ___________ Date: _________

Name of
Province/City/ Total no. Total duration of signs & Total decision of health
Municipality/ of Sex symptoms (per day) Total result Total Case Classified worker Remarks
Facility dengue
(RHU/BHS) suspect M F 1 2 3 4 5 Negative Positive Indeterminate Suspect Probable Non-dengue HM Referral Other disease

Total

Percent
Prepared by: Name & Signature: ______________________________________ Noted by: Name & Signature:____________________________________
Position: _______________________________________________ Position: ______________________________________________
 DENGUE NS1 RDT REGISTRY

Region: __________ Province: _________________________ Municipality: _________________________________

Name of Trained Health Worker: ________________________ Contact Number: ___________________ Year: __________ Quarter: ___________

Date of Onset of Result of NS1 RDT

Collection/ Date Signs &
Examination Case No. Dengue Suspect of Sex Address & Contact Number Symptoms Positive (P)
Negative (N) Repeat
No (mm/dd/yy) (year-xxxx) (Last Name, First Name, M.I) Age Birth (M/F) (street,barangay, municipality) (No. of Days) Indeterminate (I) Exam Examined by

10
Total No. Positive Total No. Dengue (suspect)
Total No. Negative Total No. Dengue (probable)
Total No. Repeat Exam Total No. Non-deengue
__________________________
uarter: ___________

Case Decision
Classification of Health
Suspect (S) Probable (P)
Non-dengue (ND) Worker Remarks

otal No. Dengue (suspect)

otal No. Dengue (probable)
otal No. Non-deengue