VISIT 1 MALARIA DIAGNOSTIC TEST LB Date Time Was malaria RDT performed? Yes No NA |__|__|-|__|__|__|-|__|__|__|__| |__|__|:|__|__| MBPERFYN NOT SUBMITTED MBDAT MBDTC MBTIM MBDTC Lot number name Test type Result Not done Reason not done DIVAL when DIVAL when MBTESTCD/MBTEST MBORRES MBSTAT MBREASND DIPARM=Lot DIPARM=Trade Name Pf Pf+Pan Pan Other Positive Negative Invalid If other, specify ______________________ MICROSCOPY = MALARIA MICROSCOPY REPEAT AS PER PROTOCOL Reader Parasite Slide Collection date and time Smear type Parasite count Parasite count units Malaria species number type quality MBDAT MBDTC MBMETHOD MBORRES MBORRESU MBTESTCD/TEST MBEVAL, MBTESTCD/ SDQUAL MBEVALID TEST Good Thick smear /_____WBC /_____HPF Pf Pv Po Asexual |__|__|-|__|__|__|-|__|__|__|__| |__|__|__|__| Poor Thin smear /_____RBC Pm Pk Missing Thick smear Sexual /_____WBC /_____HPF |__|__|:|__|__| |__|__|__|__| MBTIM MBDTC Good Thick smear /_____WBC /_____HPF Asexual Pf Pv Po |__|__|-|__|__|__|-|__|__|__|__|
VISIT 1 MALARIA DIAGNOSTIC TEST LB Was malaria RDT performed? MBPERFYN NOT SUBMITTED Yes No NA Date MBDAT MBDTC |__|__|-|__|__|__|-|__|__|__|__| Time MBTIM MBDTC |__|__|:|__|__| Test type MBTESTCD/MBTEST Lot number DIVAL when DIPARM=Lot name DIVAL when DIPARM=Trade Name Result MBORRES Not done MBSTAT Reason not done MBREASND Pf Pf+Pan Pan Other If other, specify ______________________ Positive Negative Invalid MICROSCOPY = MALARIA MICROSCOPY REPEAT AS PER PROTOCOL Collection date and time MBDAT MBDTC Reader number MBEVAL, MBEVALID Slide quality SDQUAL Smear type MBMETHOD Parasite type MBTESTCD/ TEST Parasite count MBORRES Parasite count units MBORRESU Malaria species MBTESTCD/TEST |__|__|-|__|__|__|-|__|__|__|__| Good Thick smear Asexual |__|__|__|__| /_____WBC /_____HPF Pf Pv Po Poor Thin smear /_____RBC Pm Pk |__|__|:|__|__| MBTIM MBDTC Missing Thick smear Sexual |__|__|__|__| /_____WBC /_____HPF |__|__|-|__|__|__|-|__|__|__|__| Good Thick smear Asexual /_____WBC /_____HPF Pf Pv Po
wwarn-malaria-case-record-form-crf-v1-january-2017.docx