Community Measles Outbreak Suspected Case Form
Full Name
Age
Sex
Male
Female
Other
Date of Birth
Address
Contact Number
Date of Onset of Symptoms
Fever
Yes
No
Rash
Yes
No
Cough
Yes
No
Runny Nose
Yes
No
Red Eyes (Conjunctivitis)
Yes
No
Recent Travel
Vaccination Status
Not Vaccinated
Partially Vaccinated
Fully Vaccinated
Unknown
Contact with Suspected/Confirmed Case
Yes
No
Unknown
Other Symptoms or Notes