Malaria Case Report Form
Submit details for a suspected or confirmed malaria case. Please complete all fields accurately.
Report Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reporting Facility Name
*
Patient Age (years)
*
Patient Sex
*
Male
Female
Other
Patient Residence (City/Town/Village)
*
Symptom Onset Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Malaria Test Type
*
Please Select
Microscopy
Rapid Diagnostic Test (RDT)
Other
Malaria Test Result
*
Positive
Negative
Not Available
Malaria Species (if known)
Please Select
Plasmodium falciparum
Plasmodium vivax
Plasmodium malariae
Plasmodium ovale
Mixed
Unknown
Treatment Started
*
Yes
No
Case Severity / Outcome / Referral Status
*
Please Select
Uncomplicated
Severe
Recovered
Referred
Deceased
Submit Report
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