PATIENT EXPOSURE (Tick appropriate boxes) HISTORY 1 of the following exposures within 3 weeks before onset of symptoms: Exposure date or period: ≥ Tick bites Squashing ticks Slaughtered cattle or sheep Contact or other body fluids from animal Contact with blood or other body fluids of patient with Work in laboratory that handles VHF samples CCHF Travel to African VHF (CCHF, Ebola, Marburg, Lassa, Lujo virus) endemic countries If yes, country: Contact with bats, rodents, or primates from VHF endemic countries Circumstance: PATIENT TREATMENT AND OUTCOME Outcome date: __/__/____ Treatment(s) given? Date: __/__/____ Response: Responsive Outcome: Uneventful recovery Not responsive Recovery with sequelae Deceased Complications POST COMPLETED FORM WITH SPECIMEN TO: FAX OR EMAIL COMPLETED Special Viral Pathogens Lab, National Institute for Communicable Diseases, National FORM TO: Health Laboratory Service, 1 Modderfontein Road, Sandringham 2192, South Africa 0865964423 or cezd@nicd.ac.za
PATIENT EXPOSURE HISTORY (Tick appropriate boxes) ≥ 1 of the following exposures within 3 weeks before onset of symptoms: Exposure date or period: Tick bites Squashing ticks Slaughtered cattle or sheep Contact or other body fluids from animal Contact with blood or other body fluids of patient with CCHF Work in laboratory that handles VHF samples Travel to African VHF (CCHF, Ebola, Marburg, Lassa, Lujo virus) endemic countries If yes, country: Contact with bats, rodents, or primates from VHF endemic countries Circumstance: PATIENT TREATMENT AND OUTCOME Outcome date: __/__/____ Treatment(s) given? Date: __/__/____ Response: Responsive Outcome: Uneventful recovery Not responsive Recovery with sequelae Deceased Complications POST COMPLETED FORM WITH SPECIMEN TO: Special Viral Pathogens Lab, National Institute for Communicable Diseases, National Health Laboratory Service, 1 Modderfontein Road, Sandringham 2192, South Africa FAX OR EMAIL COMPLETED FORM TO: 0865964423 or cezd@nicd.ac.za