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 ()) :

Kolera  Poli  Malaria  Hepatitis  Chikungunya 

Pes  Difteri  Avian Influenza (H5N1)  H5N1 (2009)  Keracunan 

DBD  Pertusis  Antraks  Meningitis  ................ 

Campak  Rabies  Leptospirosis  Yellow Fever  ................ 

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.