Ebola Virus Disease

Medical Forms & Surveillance Guidelines

Standardized Case Reporting and Contact Tracing Protocols
Ministry of Health & Family Welfare

Annexure III

Examination of Passenger under Observation

Annexure III

Passenger Examination Form

Personal Information

Name
Age in years
Sex
Complete Address
Home phone with STD code
Mobile number

Travel History

Countries visited in last 21 days
Date of travel from Ebola affected country

Clinical Assessment

Fever
Yes / No
Sore Throat
Yes / No
Headache
Yes / No
Intense Weakness
Yes / No
Myalgia
Yes / No
Internal Bleeding
Yes / No

Action Required: In case of any symptoms, the passenger should be immediately isolated at designated hospital.

Page 16 of 30

Annexure IV

Case Report Form (CRF) for Ebolavirus Infection

Annexure IV - Section 1

Administrative & Reporting Details

Identification

CRF ID
Outbreak/Cluster/Hospital ID
State/UT
District
Name of Hospital/Facility
Facility Type (PHC/CHC/District Hospital)
Isolation unit/ward

Timeline

Date of symptom onset
Date of Admission
Date of sample collection
Name and designation of person completing form

Patient Identifiers

Full name
Hospital registration number
National ID/Aadhaar/Passport
Age & Gender
Nationality & Occupation
Current & Permanent address
Phone numbers of patient/relative
Treating physician contact
Page 17-18 of 30
Annexure IV - Sections 3 & 4

Case Status & Epidemiological Risk

Case Classification

  • Suspected / Probable / Confirmed
  • Disease under investigation
  • Specific virus/species if known
  • Basis for classification
  • Public health notified
  • Isolation initiated

Travel History (21 days before onset)

  • International travel
  • Countries/cities visited
  • Dates of travel
  • Mode of travel (Air/Road/Sea)
  • Flight/ship details
  • Stayed in outbreak area

Contact with Known/Suspected Cases

Staying with/caring for ill person
Direct physical contact with VHF case
Contact with body fluids
Shared bed, linen, clothing, utensils
Healthcare exposure without PPE
Needle-stick or sharps exposure
Participation in burial/funeral
Sexual contact with survivor
Page 18-19 of 30
Annexure IV - Section 6

Clinical Symptoms & Signs

Symptom Present Symptom Present
Fever Yes / No Conjunctival injection Yes / No
Chills/rigors Yes / No Rash Yes / No
Fatigue/profound weakness Yes / No Mucosal bleeding Yes / No
Headache Yes / No Hematemesis Yes / No
Myalgia Yes / No Melena Yes / No
Sore throat Yes / No Hematochezia Yes / No
Cough Yes / No Hematuria Yes / No
Shortness of breath Yes / No Vaginal bleeding Yes / No
Nausea/Vomiting Yes / No Epistaxis/Gum bleeding Yes / No
Diarrhoea Yes / No Bruising/Petechiae Yes / No

Vital Signs

Temperature (°C)
Heart rate/min
Respiratory rate/min
Blood pressure (mmHg)
SpO2 on room air
Mental status/GCS
Page 21-22 of 30
Annexure IV - Sections 8-17

Laboratory Tests & Patient Outcome

Hematology

  • Hb, WBC, Platelets
  • PT, aPTT, INR
  • Fibrinogen, D-dimer
  • Peripheral smear

Biochemistry

  • Urea, Creatinine
  • Electrolytes (Na, K, Cl)
  • AST, ALT, ALP
  • CRP, Procalcitonin

Ebolavirus-Specific Laboratory Diagnosis

Serum
Whole Blood [EDTA]
Urine samples
Stool samples/Rectal swab
Oropharyngeal/Nasopharyngeal Swabs
Tissue/autopsy specimen

Outcome

  • Final case classification
  • Outcome: Recovered/Discharged/Died
  • Date of discharge/death
  • Total hospital stay (days)

Treatments

  • IV fluids, Vasopressors
  • Blood products
  • Oxygen/Mechanical ventilation
  • Antiviral/Monoclonal antibodies
Page 23-27 of 30

Annexure V

Format for Daily Reporting by State Surveillance Unit

Annexure V

Daily Reporting Format

State Surveillance Unit Reporting

To be submitted daily by State Surveillance Unit to monitor outbreak progression and response activities.

Case Summary

  • New suspected cases
  • New probable cases
  • New confirmed cases
  • Total cases under monitoring
  • Cases discharged
  • Deaths

Contact Tracing

  • New contacts identified
  • Contacts under follow-up
  • Contacts completed follow-up
  • Contacts developed symptoms
  • Contacts isolated

Reporting Elements

Date of report
State/UT name
Districts affected
Active outbreak sites
Healthcare facilities activated
Laboratory samples tested
Isolation facilities occupied
Contact tracing teams deployed

Reporting Frequency: Daily submission by 5:00 PM to Central Surveillance Unit

Page 28 of 30

Annexure VI

Formats for Contact Listing and Follow-up

Annexure VI - Contact Information

Contact Listing Format

Case Information

Name of case
Age (years)
Sex (M/F)
Head of Household
Address
District
Date of Symptom Onset

Contact Information

S. No. Name Age Sex Relation to case Address Phone Health Care Worker
1 Y/N
2 Y/N
3 Y/N

Distribution: To be filled and updated by DSU in consultation with SSU. DSU will circulate this list to MPHW/ANM/ASHA/Volunteer for Contact Follow up.

Page 29 of 30
Annexure VI - Follow-up Form

Contact Follow-up Form

Form Details

Contact Follow Up Form Filled By
Address of the Contact
District

21-Day Follow-up Tracking

S. No. Name Age Sex Date of last contact Day of following (1-21)
1

Follow-up Instructions

  • Put a 'x' if the contact has no symptom
  • Put a '✓' if the contact has any one of the symptoms:
  • Fever / Headache / Diarrhea / Intense weakness / External Bleeding

To be shared with: Health Supervisor / District Nodal Officer / District Epidemiologist

Page 30 of 30
Summary

Key Forms & Their Purpose

Annexure III

Passenger Examination
For screening travelers arriving from Ebola-affected countries. Captures personal details, travel history, and clinical symptoms to identify potential cases at points of entry.

Annexure IV

Case Report Form (CRF)
Comprehensive form for suspected, probable, and confirmed VHF cases. Covers administrative details, epidemiological risk, clinical symptoms, laboratory tests, treatment, and outcome.

Annexure V

Daily Reporting
State Surveillance Unit format for daily outbreak monitoring. Tracks new cases, contact tracing progress, and response activities for centralized surveillance.

Annexure VI

Contact Listing & Follow-up
Two-part system: Contact Information form for listing all exposed individuals, and 21-day Follow-up Form for daily symptom monitoring by health workers.

Important: All forms are designed for Ebolavirus species including Zaire, Sudan, Bundibugyo, Taï Forest, and Reston orthoebolaviruses. They can also be adapted for Marburg virus disease and Lassa fever with minimal modifications.