Current Malaria Form

MALARIA CASE SURVEILLANCE REPORT
Department of Health and Human Services, Centers for Disease Control and Prevention
Division of Parasitic Diseases (MS F-22), 4770 Buford Highway, N.E. Atlanta, Georgia 30341

State Case No: .......................
Patient name (last, first):

CSID No................................
Case No: .........................
Sex:
Age: _______ yrs. mos. wks. days (circle units)
Date of Birth: ____/ ____/ ________
Male
No
Date of symptom onset of this attack (mm/dd/yyyy): ____/ ____/ _____ Is patient pregnant? Yes
Female
Unknown
Physician name (last, first):
Ethnicity:
Race (select one or more):
Hispanic or Latino
American Indian/Alaska Native
Not Hispanic or
Native Hawaiian/Other Pacific Islander
Black or African American
Latino
Telephone Number: (
) _________ – ___________
Asian
White
Unknown
Positive lab test result (check all that apply):
State/territory reporting this case: ___________________
Smear
PCR
RDT
No test done/unknown
County: ___________________
Species (check all that apply):
Patient admitted to hospital: Yes
No
Unknown
Vivax
Falciparum
Malariae
Ovale
Not Determined
Hospital: _______________________________________
Other species (specify) __________________
Date: ____/ ____/ ________ Hospital record No.: ________
Parasitemia (%): _______________________
Laboratory name:

Specimens being sent to CDC?

Telephone Number: (

) _________ – ___________

If yes:

Smears

Yes

No

Has the patient traveled or lived outside the U.S. during the past 2 years?
Country:

1. ________________

Yes

Whole Blood

No

Unknown

Other: _______________

If yes, specify:

2. _________________

3. ___________________

Date returned/ arrived in U.S. (mm/dd/yyyy):

____/ ____/ ______

____/ ____/ ________

____/ ____/ ________

Duration in country yrs.

_________________

__________________

___________________

mos. wks. days (circle units)

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

Principal reason for travel from/ to U.S. for most recent trip:
Tourism
Visiting friends/relatives
Student/teacher
Military
Airline/ship
crew
Other: ____________
No, (specify country): _____________________
Business
Missionary or dependent
Unknown
Unknown
Peace Corps
Refugee/immigrant
Was malaria chemoprophylaxis taken?
Yes
No
Unknown
Mefloquine
Doxycycline
Primaquine
Atovaquone/proguanil
If yes, which drugs were taken? Chloroquine
Other: ______________________________
Unknown
History of malaria in last 12 months (prior to this report)?
If doses were missed, what was the reason?
Were all pills taken as
Yes
No
Unknown
Forgot
prescribed?
Didn’t think needed
Date of previous illness: ____/ ____/ ________
Yes, missed no doses
Had a side effect (specify): ________________
If yes, species (check all that apply):
Was advised by others to stop
No, missed doses
Prematurely stopped taking once home
Vivax
Falciparum
Malariae
Ovale
Other (specify): _________________________
Unknown
Not Determined
Other (specify) _____________
Unknown
Blood transfusion/organ transplant within last 12 months: Yes
Clinical
Cerebral malaria
ARDS
Renal failure
Severe anemia(Hb<7)
Complications:

No
Unknown
If yes, date: ____/ ____/ ________
None
Was illness fatal:
Yes
No
Unknown
Other : ____________ If yes, date of death : _____/____/_______

Therapy for this attack (check all that apply):
Chloroquine
Primaquine

Tetracycline
Quinine

Doxycycline
Quinidine

Mefloquine
Clindamycin

Person submitting report:
Affiliation:
For CDC Use Only.

Exchange transfusion
Atovaquone/proguanil

Artesunate
Unknown
Other (specify): ____________

Telephone No. :
Date Submitted: __________/__________/_____________
Classification

Imported

Induced

Introduced

Congenital

Cryptic

Public reporting burden of this collection of information is estimated to average 15 minutes per response. An agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information unless it displays a currently valid OMB control number. Please send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Rd., NE (MS D-24); Atlanta, GA 30333; ATTN: PRA (0920-0009).

CDC 54.1 12/2008(Front) OMB 0920-0009
If sending specimens, please forward blood smears (thick and thin) with this report.

Physicians and other health care providers with questions about diagnosis and treatment of malaria
cases can call CDC’s Malaria Hotline:
- Monday – Friday, 8:00 am to 4:30 pm, EST: call 770-488-7788 (Fax: 770-488-4465)
- Off-hours, weekends, and federal holidays: call 770-488-7100 and ask to have the malaria
clinician on call paged.
Information on malaria risk, prevention, and treatment is available at:
- CDC’s Travelers’ Health Web site http://www.cdc.gov/travel
- CDC’s Travelers’ Health Information Service: call 1-877-FYI-TRIP
- CDC’s Malaria Web site http://www.cdc.gov/malaria
Health Information for International Travel is available from the Public Health Foundation:
Call 1-877-252-1200, or order on line at http://www.phf.org

CDC 54.1 12/2008 (Back)

If sending specimens, please forward blood smears (thick and thin) with this report.