Medical Abstraction Form

Clinical Data Collection Tool

Health facility ID:

-

Individual ID:

-

Date:

-

-

2

0

Day(XX) Month(XXX) Year(XXXX)

Patients’ village of residence:

Date of Birth:

-

-

-

Age:

-

Gender:

Male

Female

Day(XX) Month(XXX) Year(XXXX) Years (If less than 1 year, record age in months)

Number of days since diarrheal episode:

Number of days diarrheal episode lasted:

Number of stools in a 24 hours:

3

4

5

6

7

>7

TNTC

(TNTC –too numerous to count)

Other symptoms:

Fever (≥38C) by caregiver report:	Yes	No	-	Loss of consciousness:	Yes	No	-	Convulsions:	Yes	No	-
Vomiting:	Yes	No	-	Abdominal (belly) pain:	Yes	No	-	Unable to drink:	Yes	No	-
Difficulty breathing:	Yes	No	-	Weight loss:	Yes	No	Unknown	Bloody stools:	Yes	No	-

Received antibiotics before coming to the health facility:	Yes	No	Don’t know
If yes, how many days of antibiotics:	1	2	3	4	5	6	7	Don’t know
If less than 1 day, has it been less than 12 hours:	Yes	No
Antibiotic name: _________________________

If the child is <5 years old, did they receive the rotavirus vaccine?

Yes

No

Don’t know

If yes please record the following information from the vaccine card, received rotavirus vaccine:

Yes

Not recorded

If not recorded skip to “Clinic Visit Information”

If yes, how many doses:	1	Date:			-				-	2	0
	2	Date:			-				-	2	0
	>2	Date:			-				-	2	0

Day(XX) Month(XXX) Year(XXXX)

Clinic Visit Information (information provided by nurse/study coordinator):

Temperature:

_____

C

Not collected

-

Weight:

______

Kg

Not collected

Referred:

Yes

No

-

Admitted:

Yes

No

Zinc prescribed:

Yes

No

-

Oral rehydration:

Yes

No

-

IV rehydration:

Yes

No

Antibiotics prescribed:

Yes

No

Antibiotics

Amoxycillin:	Yes	No	-	Ampicillin:	Yes	No	-	Azithromycin:	Yes	No
Chloramphenicol/Thiamphenicol:	Yes	No	-	Ciprofloxacin:	Yes	No	-	Clotrimoxazole/Spetrin:	Yes	No
Erythromycin:	Yes	No	-	Gentamycin:	Yes	No	-	Nalidixic acid	Yes	No
Penticillin:	Yes	No	-	Selexid/Pivmecillinam	Yes	No	-	Other:_____________

Collection time:

-

Collection date:

-

-

2

0

Time in 24 hours Day(XX) Month(XXX) Year(XXXX)

Stool collected from:

Directly

Part of already collected specimen

Diaper

Specimen ID:							Place specimen sticker here
Lab ID:

Notes and Comments:

(Initial and date any notes or comments)

Interviewer’s Name/Signature: ________________________

Quality Reviewer’s Name/Signature:_________________

Quality Review Date:

-

-

2

0

Day(XX) Month(XXX) Year(XXXX)

Lab Collection Information

Specimen ID:
Lab ID:

Collection time:

-

Collection date:

-

-

2

0

Time in 24 hours Day(XX) Month(XXX) Year(XXXX)

Stool collected from:

Directly

Part of already collected specimen

Diaper

Notes and Comments:

(Initial and date any notes or comments)

Interviewer’s Name/Signature: ________________________

Quality Reviewer’s Name/Signature:_________________

Quality Review Date:

-

-

2

0

Day(XX) Month(XXX) Year(XXXX)

Lab Results Form

Specimen ID:
Lab ID:

Time results reported:

-

Date results reported:

-

-

2

0

Time in 24 hours Day(XX) Month(XXX) Year(XXXX)

Parasites:

Cryptosporidium:	Pos	Neg	NT	Giardia:	Pos	Neg	NT
Ascaris:	Pos	Neg	NT	Hookworm:	Pos	Neg	NT
No parasites isolated:	Yes	No		E. histolytica

Pos: Positive; Neg: Negative; NT; Not Tested

Virus:

Rotavirus EIA:

Positive

Negative

NT

Bacteria:

Campylobacter jejuni:

Pos

Neg

NT

Campylobacter coli:

Pos

Neg

NT

Campylobacter unspecified:

Pos

Neg

NT

Salmonella Typhi:

Pos

Neg

NT

Salmonella enterica non-Typhi:

Pos

Neg

NT

Shigella dysenteriae:	Pos	Neg	NT	Shigella flexneri:	Pos	Neg	NT	Shigella boydii:	Pos	Neg	NT
Shigella sonnei:	Pos	Neg	NT	Shigella non-typable:	Pos	Neg	NT

Vibrio cholerae O1:	Pos	Neg	NT	V. cholerae O139:	Pos	Neg	NT	V. cholerae non-O1/non-O139:	Pos	Neg	NT
V.cholerae Ogawa:	Pos	Neg	NT	V. cholerae Inaba:	Pos	Neg	NT
V.parahaemolyticus:	Pos	Neg	NT	V. non-cholera/non-paraheamolyticus:	Pos	Neg	NT

E. coli:

Pos

Neg

NT

PCR Results:

No bacteria isolated:

Yes

No

No growth:

Yes

No

Pos: Positive; Neg: Negative

Notes and Comments:

(Initial and date any notes or comments)