W1 - Puskesmas

LAPORAN KEJADIAN LUAR BIASA / WABAH

(dilaporkan dalam 24 jam)

No. : ............................................................................
Kepada Yth. : ............................................................................
Pada tanggal/bulan/tahun : ............................................................................
Desa/Kelurahan : ............................................................................
Di kecamatan : ............................................................................
Telah terjadi sejumlah : .............................................................penderita
Dan sejumlah : .............................................................kematian

Tersangka penyakit (beri tanda ceklist ()) :

Diare  Campak  Tetanus Neonatorum  Hepatitis  Rabies 

Kolera  Difteri  Polio/AFP  Ensefalitis  Pes/Antraks 

DHF  Pertusis  Malaria  Meningitis  Keracunan 

DSS  Tetanus  Frambusia  Tifus Abdominalis  .............. 

Dengan gejala-gejala sebagai berikut (beri tanda ceklist ()) :

Muntah  Panas/demam  Bercak putih pada faring 
Berak-berak  Batuk  Meringkil pada lipatan pahak/ketiak 
Menggigil  Pilek  Perdarahan 
Turgor jelek  Pusing  Gatal-gatal 
Kaku kuduk  Kesadaran menurun  ........................................... 
Sakit perut  Pingsan  ........................................... 
Hidrofobi  Bercak merah di kulit  ........................................... 
Kejang-kejang  Lumpuh  ........................................... 
Syok  Ikterus  ........................................... 
Batuk beruntun  Mulut sukar dibuka  ............................................. 

Tindakan yang telah diambil :

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Kepala Puskesmas

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NIP.