Get (afp) Surveillance Form

This guide provides clear instructions for users on how to complete the Acute Flaccid Paralysis (AFP) Surveillance Form online. By following these steps, you can ensure that all required information is accurately submitted for effective surveillance and reporting.

Follow the steps to successfully complete the AFP Surveillance Form.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by filling out the 'Patient Details' section, which includes inputting the HSE ID, surname, forename, address, county, hospital chart number, and the patient's date of birth, hospital admission date, and discharge date (if known). These details are essential for identifying the patient.
3. Next, complete the 'Reporting Clinician’s Details' by entering the hospital name, consultant's name, and their email. Include the referring hospital and consultant information as well.
4. Move on to the 'GP Details' section. Fill in the GP's name, address, telephone number, and email. This information is vital for any further contact regarding the patient.
5. Proceed to the 'Clinical Features and Investigations' section. You will need to provide details regarding the onset and characteristics of the paralysis, presence of fever, hospitalisation status, and whether the patient was immunosuppressed.
6. Specify details regarding any investigations performed, such as EMG, nerve conduction studies, and spinal MRI. For each, indicate the date and results where applicable.
7. In the subsection for 'Other Investigations and Results', document any relevant tests such as throat swabs and lumbar punctures, including results and dates.
8. Continue to the 'Patient Vaccination History' section, detailing the patient's immunization status against polio and any recent contacts with individuals who received oral polio vaccine.
9. Identify the diagnosis based on available evidence. Check the relevant diagnoses from the provided list, and provide any additional comments as necessary.
10. Finally, complete the 'Outcome at the Time of Reporting' section. Document the date of follow-up, whether the patient survived, and any residual paralysis or sphincter dysfunction. Use this space to capture any further information on the back of the questionnaire.
11. Once all sections are filled, review the form for accuracy. Users can then save changes, download, print, or share the completed form as needed.

Take the next step now and complete your AFP Surveillance Form online.