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Suspected case report (NERC)

Suspected case report (NERC)
Ebola rapid case identification
0%
Exit Survey
 
 
Hello!
This questionnaire is to identify and report possible Ebola cases in your area. By going through all the questions you will create a full information report that is submitted to the health authorities. Please ensure that you fill out all questions according to the person´s answers. This reporting tool will help to combat the deadly Ebola outbreak in Sierra Leone. We hope for your collaboration and support.

The Balmed Ebola Response Team
 
 
 
 
Specify your Province or Area
 
Eastern Province
 
Southern Province
 
Northern Province
 
Western Area
 
 
 
Specify your District in the Eastern Province
 
Kenema
 
Kono
 
Kailahun
 
 
 
Specify your District in the Southern Province
 
Bo
 
Pujehun
 
Moyamba
 
Bonthe
 
 
 
Specify your District in the Northern Province
 
Koinadugu
 
Kambia
 
Tonkolili
 
Port Loko
 
Bombali
 
 
 
Specify your area in the Western Area
 
Western urban (Freetown)
 
Western rural
 
 
 
Please specify the chiefdom in Kenema District
 
Gorama Mende
 
Wandor
 
Simbaru
 
Kando Leppeama
 
Dodo
 
Lower Bambara
 
Malegohun
 
Small Bo
 
Niawa
 
Langorama
 
Nongowa
 
Dama
 
Koya
 
Gaura
 
Tunkia
 
Nomo Faama
 
 
 
Please specify the chiefdom in Kailahun District
 
Jalahun
 
Jawie
 
Mandu
 
Upper Bambara
 
Malema
 
Dia
 
Luawa
 
Kissi Teng
 
Kissi Kama
 
Kissi Tongi
 
Pengula
 
Peje West
 
Peje Bongre
 
Yawei
 
 
 
Please specify the chiefdom in Kono District
 
Gorama Kono
 
Nimikoro
 
Nimiyama
 
Sandor
 
Gbane
 
Gane Kandor
 
Kamara
 
Gbense
 
Tonkoro
 
Lei
 
Soa
 
Toli
 
Mofindor
 
Fiama
 
 
 
Please specify the chiefdom in Bo District
 
Badjia
 
Bagbe
 
Bagbo
 
Baoma
 
Bumpeh
 
Gbo
 
Jiama-Bongor
 
Kakua
 
Komboya
 
Lugbu
 
Niawa Lenga
 
Sieienga
 
Tikonko
 
Valunia
 
Wunde
 
 
 
Please specify the chiefdom in Bonthe District
 
Kpanda Kemo
 
Yawbeko
 
Jong
 
Benducha
 
Nogoba Bullom
 
Sittia
 
Kawameba Krim
 
Bum
 
Imperi
 
Dema
 
Sogbini
 
 
 
Please specify the chiefdom in Pujehun District
 
Sowa
 
Pejeh
 
Barri
 
Makpele
 
Soro Gbema
 
Gallinasperi
 
Kpaka
 
Panga Krim
 
Panga Kabonde
 
Yakemo Kpukumu Krim
 
Malen
 
Mano Sakrim
 
 
 
Please specify the chiefdom in Moyamba
 
Bumpeh
 
Ribbi
 
Kongbora
 
Kaiyamba
 
Bagruwa
 
Timdel
 
Kagboro
 
Fakunya
 
Kori
 
Dasse
 
Kamajei
 
Banta Gbanbatoke
 
Banta Mokele
 
Kowa
 
 
 
Please specify the chiefdom in Bombali District
 
Bombali Shebora
 
Makari Gbanti
 
Paki Massabong
 
Leibasgayahun
 
Sanda Tendaren
 
Magbalamba Ngowahun
 
Gbanti Kamaranka
 
Sanda Loko
 
Sella Limba
 
Tambakka
 
Gbendembu Ngowahun
 
Safroko Limba
 
Briwa
 
 
 
Please specify the chiefdom in Kambia District
 
Bramaia
 
Gbinle Dixing
 
Magbema
 
Mambolo
 
Masungbala
 
Samu
 
Tonoko Limba
 
 
 
Please specify the chiefdom in Koinadugu District
 
Kassunko
 
Diaug
 
Neini
 
Wara Wara Yagala
 
Wara Wara Bafodia
 
Sengbe
 
Follosaba Dembelia (musala)
 
Dembelia Sinkunia
 
Mongo
 
Sulima
 
Neya
 
 
 
Please specify the chiefdom in Port Loko District
 
Kaffu Bullom
 
Loko Massama
 
Maforki
 
Bureh
 
Dibia
 
Sanda Magblonthor
 
Tinkatinpa Makama Saffroko
 
Koya
 
Masimera
 
Buya Romende
 
Maramapa
 
 
 
Please specify the chiefdom in Tonkolili
 
Kholifa Mabang
 
Yoni
 
Malal Mara
 
Kholifa Rowalla
 
Tane
 
Gbonkolenken
 
Konike Barina
 
Konike Sanda
 
Sambala Bendugu
 
Kalansogia
 
Kafe Simira
 
 
 
What is the name of the section?
   
 
 
 
What is the name of the community/adress?
   
 
 
 
Specify the gender of the person
 
Female
 
Male
 
 
 
Are details of the person (name, age, phone ect.) available?
 
Yes
 
No
 
 
 
What is the surname of the person?
   
 
 
 
What is the name of the person?
   
 
 
 
Enter the day of birth of the person
 
 
 
Enter the age of the person
   
 
 
 
Enter a contact phone number of the person.
   
 
 
 
Please specify the Province or Area where the person is from
 
Eastern Province
 
Southern Province
 
Northern Province
 
Western Area
 
 
 
Please specify the District (east) where the person is from
 
Kenema
 
Kono
 
Kailahun
 
 
 
Please specify the chiefdom in Kenema District
 
Gorama Mende
 
Wandor
 
Simbaru
 
Kando Leppeama
 
Dodo
 
Lower Bambara
 
Malegohun
 
Small Bo
 
Niawa
 
Langorama
 
Nongowa
 
Dama
 
Koya
 
Gaura
 
Tunkia
 
Nomo Faama
 
 
 
Please specify the chiefdom in Kailahun District
 
Jalahun
 
Jawie
 
Mandu
 
Upper Bambara
 
Malema
 
Dia
 
Luawa
 
Kissi Teng
 
Kissi Kama
 
Kissi Tongi
 
Pengula
 
Peje West
 
Peje Bongre
 
Yawei
 
 
 
Please specify the chiefdom in Kono District
 
Gorama Kono
 
Nimikoro
 
Nimiyama
 
Sandor
 
Gbane
 
Gane Kandor
 
Kamara
 
Gbense
 
Tonkoro
 
Lei
 
Soa
 
Toli
 
Mofindor
 
Fiama
 
 
 
Please specify the District (south) where the person is from
 
Bo
 
Pujehun
 
Moyamba
 
Bonthe
 
 
 
Please specify the chiefdom in Bo District
 
Badjia
 
Bagbe
 
Bagbo
 
Baoma
 
Bumpeh
 
Gbo
 
Jiama-Bongor
 
Kakua
 
Komboya
 
Lugbu
 
Niawa Lenga
 
Sieienga
 
Tikonko
 
Valunia
 
Wunde
 
 
 
Please specify the chiefdom in Bonthe District
 
Kpanda Kemo
 
Yawbeko
 
Jong
 
Benducha
 
Nogoba Bullom
 
Sittia
 
Kawameba Krim
 
Bum
 
Imperi
 
Dema
 
Sogbini
 
 
 
Please specify the chiefdom in Pujehun District
 
Sowa
 
Pejeh
 
Barri
 
Makpele
 
Soro Gbema
 
Gallinasperi
 
Kpaka
 
Panga Krim
 
Panga Kabonde
 
Yakemo Kpukumu Krim
 
Malen
 
Mano Sakrim
 
 
 
Please specify the chiefdom in Moyamba
 
Bumpeh
 
Ribbi
 
Kongbora
 
Kaiyamba
 
Bagruwa
 
Timdel
 
Kagboro
 
Fakunya
 
Kori
 
Dasse
 
Kamajei
 
Banta Gbanbatoke
 
Banta Mokele
 
Kowa
 
 
 
Please specify the District (north) where the person is from
 
Koinadugu
 
Kambia
 
Tonkolili
 
Port Loko
 
Bombali
 
 
 
Please specify the chiefdom in Kambia District
 
Bramaia
 
Gbinle Dixing
 
Magbema
 
Mambolo
 
Masungbala
 
Samu
 
Tonoko Limba
 
 
 
Please specify the chiefdom in Bombali District
 
Bombali Shebora
 
Makari Gbanti
 
Paki Massabong
 
Leibasgayahun
 
Sanda Tendaren
 
Magbalamba Ngowahun
 
Gbanti Kamaranka
 
Sanda Loko
 
Sella Limba
 
Tambakka
 
Gbendembu Ngowahun
 
Safroko Limba
 
Briwa
 
 
 
Please specify the chiefdom in Koinadugu District
 
Kassunko
 
Diaug
 
Neini
 
Wara Wara Yagala
 
Wara Wara Bafodia
 
Sengbe
 
Follosaba Dembelia (musala)
 
Dembelia Sinkunia
 
Mongo
 
Sulima
 
Neya
 
 
 
Please specify the chiefdom in Port Loko District
 
Kaffu Bullom
 
Loko Massama
 
Maforki
 
Bureh
 
Dibia
 
Sanda Magblonthor
 
Tinkatinpa Makama Saffroko
 
Koya
 
Masimera
 
Buya Romende
 
Maramapa
 
 
 
Please specify the chiefdom in Tonkolili
 
Kholifa Mabang
 
Yoni
 
Malal Mara
 
Kholifa Rowalla
 
Tane
 
Gbonkolenken
 
Konike Barina
 
Konike Sanda
 
Sambala Bendugu
 
Kalansogia
 
Kafe Simira
 
 
 
Specify your area in the Western Area
 
Western urban (Freetown)
 
Western rural
 
 
 
Please enter the name of the community or the adress, where the person is from.
   
 
 
 
Take a picture of the person
 
 
 
Describe the state of the individual
 
Person is responsive
 
Person is not responsive
 
Person is dead
 
 
 
Does the person show symptoms?
 
Yes
 
No
 
 
 
Since when does the person show symptoms?
 
Since hours
 
Since one day
 
Since few days
 
Since one week
 
Since more then one week
 
 
 
Please specify the symptoms of the person
 
Fever
 
Headache
 
Vomitting
 
Diarrhea
 
Bleeding
 
Red eyes
 
Infected tongue
 
Rash
 
Muscular pain
 
Joint pain
 
Weakness
 
Stomach pain
 
Other
 

 
 
 
Did the person come in direct contact with somebody after she or he started to show symptoms?
 
Yes
 
No
 
 
 
How many people the person came into contact with? 
 
0
 
1-5
 
6-10
 
11-15
 
over 15
 
 
 
The questionnaire is now finished. Thanks for your important support!
Please ensure that the submitted report is true and not falsified in any way.
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