CASE REPORT FORM Leptospirosis - Public Health Surveillance

Page 1 of 3CASE REPORT FORMLeptospirosisLeptospirosis EpiSurv No.Reporting AuthorityName of Public Health Officer responsible for caseNotifier IdentificationReporting source*Name of reporting sourceDate reported*nmlkj General Practitioner nmlkj Hospital-based Practitioner nmlkj Laboratorynmlkj Self-notificationnmlkj Outbreak Investigation nmlkj OtherOrganisationContact phoneUsual GP Practice GP phoneGP/Practice address Number Street SuburbCase IdentificationTown/City Post Code gfedc GeoCodeName of case* Surname Given Name(s)NHI number*EmailCurrent address* Number Street SuburbTown/City Post Code gfedc GeoCodePhone (home) Phone (work) Phone (other)Case DemographyLocation TA* DHB*Date of birth* OR Age nmlkj Days nmlkj Months nmlkj YearsSex*Occupation*nmlkj Male nmlkj Female nmlkj Indeterminate nmlkj UnknownOccupation locationNamenmlkj Place of Work nmlkj School nmlkj Pre-schoolAddress Number Street SuburbAlternative locationNameTown/City Post Code gfedc GeoCodenmlkj Place of Work nmlkj School nmlkj Pre-schoolAddress Number Street SuburbTown/City Post Code gfedc GeoCodeEthnic group case belongs to* (tick all that apply)gfedc NZ European gfedc Maorigfedc Samoangfedc Cook Island Maorigfedc Niueangfedc Chinesegfedc Indiangfedc TongangfedcOther (such as Dutch, Japanese, Tokelauan)*(specify)

Page 2 of 3Leptospirosis EpiSurv No.Basis of DiagnosisCLINICAL CRITERIAFits clinical description*nmlkj Yes nmlkj No nmlkj UnknownLABORATORY CRITERIAIsolation of Leptospira from clinical specimen*nmlkj Yesnmlkj Nonmlkj Not Donenmlkj Awaiting ResultsFour-fold or greater rise in antibody titre in paired sera bymicroagglutination test (MAT)*nmlkj Yesnmlkj Nonmlkj Not Donenmlkj Awaiting ResultsSingle high (>=400 and 800) antibody titre by microagglutination test(MAT)*nmlkj Yesnmlkj Nonmlkj Not Donenmlkj Awaiting ResultsSTATUS*nmlkj Under investigation nmlkj Probablenmlkj Confirmed nmlkj Not a caseADDITIONAL LABORATORY DETAILSSerovar (specify)*Clinical Course and OutcomeDate of onset*gfedc Approximate gfedc UnknownHospitalised*nmlkj Yesnmlkj Nonmlkj UnknownDate hospitalised*gfedcUnknownHospital *Died*Date died*Was this disease the primary cause of death?*If no, specify the primary cause of death*nmlkj YesgfedcUnknownnmlkj Nonmlkj Unknownnmlkj Yesnmlkj Nonmlkj UnknownOutbreak DetailsIs this case part of an outbreak (i.e. known to be linked to one or more other cases of the same disease)?*Risk Factorsgfedc YesExposure to farm or wild animals or their products in20 days before illness?*If yes, specify exposure in detail*If yes, specify Outbreak No.*nmlkj Yesnmlkj Nonmlkj UnknownExposure to streams, rivers, lakes in 20 daysbefore illness? (e.g. swimming, canoeing)*nmlkj Yesnmlkj Nonmlkj UnknownIf yes, specify exposure(s) in detail*Was the case overseas during the incubationperiod (range = 4-20 days) for leptospirosis?*nmlkj Yesnmlkj Nonmlkj UnknownOther risk factor for leptospirosis (specify)*Were any of these activities part of employment?*nmlkj Yesnmlkj Nonmlkj UnknownIf yes, specify*

Page 3 of 3Leptospirosis EpiSurv No.Protective FactorsIf exposure to farm animals or their products, was herd immunised against leptospirosis?*nmlkjnmlkjnmlkjnmlkjFully immunisedPartially immunisedNot immunised at allUnknownManagementCASE MANAGEMENTWere antibiotics given for this episode of leptospirosis?Date commencednmlkj Yesnmlkj Nonmlkj UnknowngfedcUnknownComments*Version 3rd August 2007* core surveillance data, ~ optional data