FORMULIR PENYELIDIKAN EPIDEMIOLOGIS (PE) DBD

Nama penderita :..............................................................................................................................................................................................................

Nama KK : .............................................................................................................................................................................................................
Alamat : .............................................................................................................................................................................................................
Kelurahan/Desa : .............................................................................................................................................................................................................
Kecamatan : .............................................................................................................................................................................................................
Hasil Pemeriksaan
Petekie/tanda
No Nama KK Nama Penderita Demam* Uji Tanda RDT RDT Jentik
perdarahan
) Tournikuet renjatan/syok IgM/IgG NS1 (+/-)
lain

*) Termasuk yang menderita panas ± 1 minggu yang lalu

Hasil PE : ……………………… (Positif**/Negatif)
Kesimpulan Ya Tidak
 Perlu pengasapan (fogging)
 Larvasidasi
 PSN 3Mplus
 Penyuluhan

**) Positif : Jika ada ≥ 1 penderita infeksi dengue lainnya dan/atau ada ≥ 3 suspek infeksi dengue, dan ada jentik
Tanggal ………………………. 20 …….
Petugas pelaksana PE

(……………………………………)