APPENDIX J - PART 1 GUIDELINES FOR USE OF AFP SURVEILLANCE FORMS Form number: AFP-H001 Title: Assessment Of Hospital Surveillance

For Acute Flaccid Paralysis. Purpose: To guide the collection of information during the initial visit to an AFP Reporting Unit. Usefulness: Completing this form will provide an understanding of the procedures, patient records, and key staff who are important for AFP surveillance. It also will assure scheduling of medical staff training in AFP surveillance. The completed form will provide a record of contact persons with their telephone numbers for each AFP RU. Routing: Form AFP-H001 is to be completed and kept with the District Immunization Officer/SMO. Form number: AFP-H002 Title: Weekly Zero Report Form. Purpose: To transmit weekly zero report data to the District Immunization Officer. Usefulness: This form is a simple summary of weekly zero reports from each Reporting Unit (RU) in the surveillance network. The nodal person at the RU reviews all wards and registry books every week, and sends in a completed form even if there were zero cases of AFP seen during the week. To collect information on AFP cases seen during the week, the nodal person should use forms H003 (smaller RU) or H003A (larger RU) to guide the search, and then transcribe results to form H002 to be sent weekly to the DIO. This helps the DIO monitor whether RUs are continuing to participate in surveillance and report any and all AFP cases. Routing: The form is completed by the nodal person responsible for AFP surveillance at each Reporting Unit, and should be reviewed and approved by the Medical Director before a copy is sent each week to the District Immunization Officer. Form number: AFP-H003/ AFP-H003A Title: Reporting Unit/Hospital Active Case Search Form. Purpose: To guide weekly searches by the designated Nodal Officer of the facility for AFP cases. Form H003 should be used in smaller RUs (those having few medical officers and without specialized departments or wards); form H003A is to be used in larger RUs, generally hospitals with specialized departments (e.g. pediatric, orthopedics etc). Usefulness: This form assures that all sources of information on AFP cases are consulted before the Weekly Zero Report Form (AFP-H002) is completed and submitted, and helps to identify those sources that are most useful in detecting and reporting cases. Routing: This form is completed by the person responsible for surveillance in each Reporting Unit, who maintains it to track weekly searches. A copy of the completed form is sent to the District Immunization Officer every 6 months.
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APPENDIX J - PART 1 Form number: AFP-D001 Title: Weekly District Report. Purpose: To transmit results of weekly zero reporting by all RUs in a district to the State EPI Officer. Usefulness: This form is a summary of weekly zero reports from all Reporting Units within a district, enabling the DIO to monitor timeliness and completeness of all RUs within the State, and to inform him/her of any AFP cases reported during the previous week. The district-level nodal person should review information from 3 sources to complete this form: D002 (rows a and d); CIFs submitted during the previous week; H-002 from all RUs. Routing: The form is completed by the person responsible for AFP surveillance in the district, using information from submitted AFP-H002. The form should be reviewed and approved by the DIO/SMO before a copy is sent each week to the State EPI Officer. Form number: AFP-D002 Title: Summary Timeliness And Completeness Of Weekly Reports. Purpose: To track the completeness and timeliness of weekly zero reporting from RUs to the District Immunization Officer. District performance is summarized by week and RU performance is summarized by quarter. Usefulness: The performance of reporting from each RU can be monitored. Line c) (% received) indicates completeness of reporting. Line e) (% on time) indicates timeliness of reporting. The minimum target for completeness of reporting is 90% of all RUs, and for timeliness is at least 80% of all RUs. Routing: Form AFP-D002 is to be completed and maintained by the District Immunization Officer, and a copy sent to the State EPI Officer at the end of each quarter. Form number: AFP-D003 Title: Active Surveillance Of AFP Reporting Units. Purpose: To monitor the frequency of active surveillance visits by SMOs to RUs, as per NPSP guidelines. Usefulness: This form allows the SMO/DIO to tell at a glance which reporting sites are due for an active surveillance visit. Routing: This form should be completed by the SMO with information obtained using Form AFP-H003 as a guide to active searches. Copies should be sent to the State EPI Officer every 3 months.

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APPENDIX J - PART 1 Form number: AFP-S001 Title: Weekly State Report. Purpose: To transmit weekly AFP surveillance findings from State level to the National Polio Surveillance Unit. Usefulness: This form provides a summary of weekly surveillance results from each State. It allows verification that case reports have been received for every case of AFP by comparing EPID numbers with case reports. Routing: The form is completed by the person responsible for AFP surveillance in each State or Union Territory, using information from submitted AFP-D001 forms. It is approved by the State EPI Officer before a copy is sent each week to the National Polio Surveillance Unit. Form number: AFP-S002 Title: Weekly Summary Of Timeliness Of District Reports. Purpose: To monitor completeness and timeliness of AFP weekly reporting by District. Usefulness: Completeness and timeliness of reporting from each District is monitored, so that districts failing to report or reporting late can be identified for corrective action. Routing: Form AFP-S002 is to be completed by the State EPI Officer using information on AFP-D002 forms submitted by each District and sent to the National Polio Surveillance Unit each quarter. Form: AFP-CIF Title: Acute Flaccid Paralysis Case Investigation Form (CIF). Purpose: To collect basic information for surveillance from cases of acute flaccid paralysis. Usefulness: This form serves as a guide to the surveillance officer to conduct the AFP case investigation, and includes all of the WHO recommended case-based data elements. By linking the clinical and geographic information for each case with results of virologic testing of stool specimens, the program can determine the precise location of circulating wild polioviruses in the country. This information will be used to focus the eradication activities in areas where poliovirus continues to spread. This information would also serve to prove the absence of wild polioviruses at later stages of the program. Routing: This form is to be completed by the DIO/SMO according to instructions in the AFP Surveillance Field Guide.

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APPENDIX J - PART 1 Form: AFP-LRF Title: Acute Flaccid Paralysis Laboratory Request Form (LRF). Purpose: To request laboratory testing of stool from AFP cases, to provide basic epidemiologic information to the virologist and to enable linking of laboratory results with epidemiologic information. Usefulness: This form will assure that stool specimens are properly identified, and that test results are available to define areas with wild poliovirus and to provide diagnostic information for surveillance officers and clinicians. Routing: (as per the AFP Surveillance Field Guide) Part I is to be completed by the case investigator (usually the DIO/SMO) who must also complete Part 6 of the AFP Case Investigation Form at the same time. The Laboratory Request Form is then sent with the stool specimens to the nearest national polio laboratory. The national laboratory will complete Part II and send the form to reference laboratory if applicable. Reference laboratory will complete part III. Form: AFP LL-case Title: Line Listing Of AFP Cases. Purpose: To maintain a chronologic list of all AFP cases, with key data elements, and to assist surveillance officers and program managers in monitoring the status of AFP case investigations. Usefulness: This form can be used by District, State, and national surveillance officers to track the progress of AFP case investigations. It will show at a glance the status of AFP case investigations, and will be useful to assure that all aspects of case investigations (including laboratory results and case classification) are completed in a timely manner. Routing: (as per the AFP Surveillance Field Guide) DIO/SMO should submit a copy of the current Line Listing of AFP cases to the State EPI Officer weekly, who will in turn send a copy of the updated state line listing to the National Polio Surveillance Unit. The same form will also be used for monthly reports from state to national level.

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APPENDIX J - PART 1 Form: AFP LL-contact Title: Line List Of Stool Specimens From Contacts Of AFP Cases. Purpose: This form can be used by district, state and national surveillance officers to track the results of stool specimens collected from healthy contacts of a Hot AFP case with inadequate stools. Such specimens are collected from 5 children aged <5 years, having close contact with an AFP case (index case) from whom adequate stools could not be collected. The isolation of wild poliovirus from any of the contact specimens is presumed evidence of wild poliovirus in the index case. Usefulness: This form shows at a glance the results of laboratory testing of stool specimens from all 5 contacts of the index case. Routing: SMO should send a copy of the line list of contact specimens collected to the NPSU. NPSU will inform the SMO of the results as they become available. Form: AFP LL-feedback Title: Feedback Form. Purpose: This form should be used by the SMO/DIO to provide feedback on every reported AFP case, to the RU or informant who notified the case. Usefulness: Provision of this information in a timely manner to the individual or facility that reported the case helps to maintain coordinated working relationships between the RUs/informants and the SMO/DIO. Knowing whether a referred case was polio (confirmed or compatible) or non-polio AFP allows the referring practitioner(s) to provide feedback to the family of the case, and may also improve their interest in and willingness to report cases in the future. Routing: This form should be completed by the SMO as the laboratory and classification results become available, and then forwarded to the referring RU or informant. Form: Weekly Surveillance Calendar Title: Calendar Of Epidemiologic Weeks For AFP Surveillance Reporting. Purpose: To provide standard intervals and numbering system for the weeks of the year, for purposes of AFP surveillance reporting. Based on the Gregorian calendar. Usefulness: The calendar shows week numbers by quarter, with dates for the beginning of each week. Week numbers are used on several reporting forms and this calendar assures they are used consistently. Routing: This is a reference document that will be updated yearly for use by all those who involved with AFP surveillance.

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