FORM PENYELIDIKAN EPIDEMIOLOGI KASUS MALARIA

Puskcsims 8
Kmbupmtcd 8
Pmdggmf Pcdycfj`jkmd 8

M. J@CDPJPMQ PCD@CRJPM
1. DMIM 8
2. Siur (tmoud + bufmd) 8
1. Qtmtus `mfmi kcfumrgm 8
0. Mfmimt
RP/RW 8
Kcfurmomd/@csm 8
Kcamimtmd 8
Kmb/Kltm 8
Prlvjdsj 8

3. Pckcrjmmd Stmim 8
Mfmimt tcipmt kcrjm 8

5. Pckcrjmmd smipjdgmd 8
Mfmimt tcipmt kcrjm 8

7. Oubudgmd `cdgmd Pcd`crjtm 8

(`jjsj mpmbjfm rcspld`cd m`mfmo lrmdg-lrmdg kldtmk)

m. Oubudgmd sc`mrmo scruimo (lrmdg tum, mdmk, smu`mrm, bukmd smu`mrm)

b. Oubudgmd tj`mk scruimo (tctmdggm, tcimd kmdtlr, tcimd scklfmo, fmjddym
scbutkmd)8

B. RJWMZMP PCDZMKJP
1. Qmkjt ymdg sckmrmdg su`mo bcrmpm fmim < omrj

2. Mdtmrm 2-0 ijdggu scbcfui smkjt ymdg sckmrmdg, mpmkmo pcrgj bcrimfmi kc fumr
`mcrmo/`csm < Zm/Pj`mk

1. Jiha Ya, sebuthan alamatnya !

RP/RW/@usud 8...................................
@csm/ 8...................................
Kcfurmomd 8...................................
Kcamimtmd 8...................................
Kmbupmtcd 8....................................
Prlvjdsj

0. Mpm gcjmfm ymdg tjibuf pm`m smkjt ymdg sckmrmdg <

m. @cimi
b. Pusjdg
a. Iumf
`. Iudtmo
c. Icdggjgjf
e. Pcgmf-pcgmf
g. @jmrc

3. Pcrdmokmd smkjt `cdgmd gcjmfm scpcrtj smkjt ymdg sckmrmdg < Zm/Pj`mk
6. Jika Ya, kapan/tanggal berapa sakit yang terakhir?

7. Tempat tinggal saat sahit tersebut dimana ?

RT/RW/Dusun :...................................
Desa/Kelurahan :...................................
Kecamatan :...................................
Kabupaten :...................................
Provinsi :....................................

8. Diagnosis yang dibuat Puskesmas : Pf/Pv/Mx

9. Tanggal Sediaan Darah dibuat :

Nomor slide Sediaan darah :

10. Tanggal pemeriksaan Sediaan Darah :

Laboratorium Pemeriksa :

11. Klasifikasi penderita :

a. Indigenous
b. Relaps
c. Import

12. Daftar Spesimen Sediaan Darah semua penghuni rumah penderita :

No No. Nama Umur JK Klinis Diagnosis

. SD
1

2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

13. Ahtivitas rutin di luar rumah pada malam hari

Jam Kegiatan Tempat Kegiatan

 18.00-20.00

20.00-22.00

22.00-24.00

00.00-02.00

02.00-04.00

04.00-06.00

Kondisi sekitar rumah

a. ada genangan air berjentik

b. ada tambak tidak terurus dan berjentik
c. banyak semak bernyamuk
d. dekat dengan hutan :..............................................Km
e. lainnya :
....................................................................................

Hasil Pemetaan

Itci Lldgjtutc Lmtjtu`c

Lokasi
Penularan/Rumah Penderita
Lokasi Oabitat1.
Uektor2
3.
4.
5.

1.
2.
Lokasi Uektor 3.
Malaria 4.
5.

Kegiatan kumpul-kumpul (kegiatan sosial) yang selalu dihadiri :

a. .........................................................................................................................................
b. .........................................................................................................................................
c.....................................................................................................................................

Kronologi Kejadian Kasus Malaria :

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Kesimpulan :

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Pewawanaara 8

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