DIARRHEA OUTBREAK

PUROK GREEN HILLS, UBALDO LAYA, ILIGAN CITY

DATE: September 21-25, 2014
STUDENT ASSIGNED: ________________________ TOTAL NO. OF FAMILY MEMBERS: _______
FAMILY NAME: _________________________ TOTAL NO. WITH DIARRHEA: ________

NAME
A
G
E
S
E
X
CHARACTER OF THE STOOL
RECOVERED

HOSPITALIZED
DIAGNOSIS
by the
doctor if
any
TAKEN:
ORS
Soup
Am
Gatorade
Kape
Juice
Loperamide
Antibiotic
Watery
Only
Watery
w/blood
Watery
w/mucus
Watery
w/ blood
and
mucus
Other
stool
character
YES NO
Discha
rged
Not
yet











DRINKING WATER SOURCE
_____NAWASA _____POSO
_____SUBA _____MINERAL WATER
_____DISTILLED WATER _____PURIFIED WATER
_____Others pls specify:_________

DRINKINGWATER PREPARATION
_____BOILED, no. of minutes: ________
_____CHLORINATED
_____NOT BOILED & CHLORINATED
_____others pls specify__________________

Frequency of Cleaning DRINKING Water Container
_____ Everyday _____4x/week
_____2x/week _____5x/week
_____3x/week _____6x/week
_____Others pls specify_______________

Frequency of Changing DRINKING WATER in Container
_____ Everyday _____4x/week
_____2x/week _____5x/week
_____3x/week _____6x/week
_____Others pls specify_______________



HAND WASHING
_______Before and After Eating Meals
_______Before and After Handling Food (cooking)
_______After Eating Only
_______Before Eating Only
_______After Handling Food (cooking)
_______Before Handling Food (cooking)

USED FOR HANDWASHING
_______Water Only ________NONE
_______Water and Soap ________other specify

USED FOR WASHING KITCHEN AND EATING UTENSILS
_____Water Only ________NONE
_____Water & Detergent ________other specify
_____Water & Dish washing liquid

WATER SOURCE FOR WASHING EATING &KITCHEN
UTENSILS, BATHING AND TOOTHBRUSH
_____NAWASA _____POSO
_____SUBA _____MINERAL WATER
_____PURIFIED WATER
_____Others pls specify:_________________