VISIT 1 MALARIA DIAGNOSTIC TEST LB Date Time Was malaria RDT performed? Yes No NA |__|__|-|__|__|__|-|__|__|__|__| |__|__|:|__|__| MBPERFYN MBDTC MBTIM MBDTC Lot number Trade 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 ______________________ MBTESTOTH MICROSCOPY MBCAT = MALARIA MICROSCOPY REPEAT AS PER PROTOCOL Parasite Reader Collection date and time Slide quality type Parasite Parasite count units Malaria species type number MBDTC SDQUAL MBMETHOD MBORRES MBORRESU MBTESTCD/TEST MBTESTCD/ MBEVALID TEST Good Thick smear Asexual Pf Pv Po |__|__|-|__|__|__|-|__|__|__|__| Poor /_____WBC /_____HPF /_____RBC |__|__|__|__| |__|__|:|__|__| Thin smear Sexual Pm Pk MBTIM MBDTC Missing Good Thick smear Asexual Pf Pv Po |__|__|-|__|__|__|-|__|__|__|__| Poor /_____WBC /_____HPF /_____RBC |__|__|__|__| |__|__|:|__|__| Thin smear Sexual Pm Pk MBTIM MBDTC Missing
VISIT 1 MALARIA DIAGNOSTIC TEST LB Was malaria RDT performed? MBPERFYN Yes No NA Date MBDTC |__|__|-|__|__|__|-|__|__|__|__| Time MBTIM MBDTC |__|__|:|__|__| Test type MBTESTCD/MBTEST Lot number DIVAL when DIPARM=Lot Trade name DIVAL when DIPARM=Trade Name Result MBORRES Not done MBSTAT Reason not done MBREASND Pf Pf+Pan Pan Other If other, specify ______________________ MBTESTOTH Positive Negative Invalid MICROSCOPY MBCAT = MALARIA MICROSCOPY REPEAT AS PER PROTOCOL Collection date and time MBDTC Reader number MBEVALID Slide quality SDQUAL type MBMETHOD Parasite type MBTESTCD/ TEST Parasite MBORRES Parasite count units MBORRESU Malaria species MBTESTCD/TEST |__|__|-|__|__|__|-|__|__|__|__| |__|__|:|__|__| MBTIM MBDTC Good Poor Missing Thick smear Thin smear Asexual Sexual |__|__|__|__| /_____WBC /_____HPF /_____RBC Pf Pv Po Pm Pk |__|__|-|__|__|__|-|__|__|__|__| |__|__|:|__|__| MBTIM MBDTC Good Poor Missing Thick smear Thin smear Asexual Sexual |__|__|__|__| /_____WBC /_____HPF /_____RBC Pf Pv Po Pm Pk
wwarn-malaria-case-record-form-crf-v2_09apr2018.docx