8.4. Proposed Event Based Surveillance Reporting Form

1. Unique identifier: (YYYY- region/district – facility code/ facility name - sequential event number)
2. Event type (multiple checks as applicable):
   1. Human [  ]
   2. Non-human [  ]
   3. Biological [  ]
   4. Radio nuclear [  ]
   5. Chemical [  ]
   6. Zoonotic [  ]
   7. Disaster [  ]
   8. Environmental [  ]
   9. Health services [  ]
   10. Other risks [  ]
3. Data source:
   1. Name of reporting person
   2. Institution of reporting person (if applicable)
   3. Phone number of reporting person
   4. E-mail of reporting person
4. Date of report (DD-MM-YYYY):
5. Date of onset of the event (or detection of the event if onset is not known) (DD-MM-YYYY):
6. Time of onset of the event if applicable (24-hour clock):
7. Geographic area (to be identified by country, e.g., region, towns, wards, etc.):
8. Description of the event (e.g., number of cases, number of deaths, actions taken so far and the outcome/result), as well as demographics (Sex & age distribution, etc. as applicable):
9. Which criteria under Annex 2 did the event meet (check all that applies)? (MOH use only)
   1. The public health impact of the event is serious [  ]
   2. The event is unusual or unexpected [  ]
   3. There is a significant risk of international spread [  ]
   4. There is a significant risk of international trade or travel restrictions [  ]
10. Laboratory Test conducted: Yes [  ] No [  ]
11. If yes, date(DD-MM-YY):
12. Brief description of lab results:
13. Risk Assessment conducted (describe : Yes [  ] No [  ]
14. Declared event: Yes [  ] No [  ]
15. Actions taken (if it is an event):

Report received by: 

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