PRELIMINARY CASE INVESTIGATION FORM

Field marked * are mandatory fields.
* Please fill 'all' mandatory fields, In mandatory text fields where information is not available, please consult your DIO/MO or enter 'Information Not Available'.

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Section A - Basic details

State

District

Block/Ward:

Block Ward

Village/Urban Area

Village Urban Area

Block

Ward

Urban Area

Village

Patient's name *

Sex*

Date of Birth *

(If exact DOB is not available please consult Dio/Mo for approximate DOB)

Age (in years)

Age (in months)

Age (in days)

Mother's name

Father's name

Complete address of the case with landmarks (street name, house number, village, block, tehsil, pin no., telephone no.)

Address *

Phone

Date of vaccination

Time of vaccination

Address of session site

Date first notified to government health system
( Note : Information in above two fields are taken from CRF and are not editable. For any changes required in these fields, please request state level user.)

Notified by (please circle)

health worker government doctor private doctor community media others(specify)

Name of vaccines received (write vaccine & diluent details in seperate rows)*	Dose no. (zero/ first / second/ etc. as applicable)*	Name of manufacturer*	Batch/Lot No.*	Expiry date Month Year		Date of opening of vial	Time of opening the vial (for reconstituted vaccine)	No. of OTHER beneficiaries who received vaccine from the SAME vial in this session*

Any other vaccine:

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Date of first symptom

Time of first symptom ( hh:mm )

Date of key symptom

Time of key symptom

Hospitalization

Date of hospitalization

Time of hospitalization ( hh:mm )

Name of hospital (if hospitalized)

Address of hospital (if hospitalized)

Current status (encircle)

If died, date of death

Time of death

Post mortem done?

If Yes, then write date post mortem done

If not done, but planned, write date planned

Section B - Relevant patient information prior to immunization

Criteria & Finding

Remarks (if "Yes" provide details)

Past history of similar event *

Adverse event after previous vaccination (s) *

History of vaccine, drug or food allergy *

Pre-existing illness (past 30 days) *

Congenital disorder *

History of hospitalization in past 30 days with reasons (in remarks column) *

Was the patient on any concomitant medication at the time of AEFI (if yes name the drug, indication, doses & treatment dates - write in remarks column) *

Family history of any disease (relevant to AEFI) or allergy *

If patient is an adult women

Currently pregnant? *

Weeks

Currently breastfeeding? *

If patient is an infant, birth details

Any birth complication(specify)

1

Birth weight: *

2

Duration of pregnancy *

3

Place of birth *

4

Delivery procedure *

Section C - Details of first examination** of reported AEFI case

Source of information ( ✔ all that apply): *

Examination by the investigator Medical case records Verbal autopsy Other

If from verbal autopsy, please mention relationship with the deceased

In case of sudden unexplained death, please also fill SUD verbal autopsy form as per the guidelines

Name of the person who first examined/treated the patient

Name of other persons from whom care was sought

Other sources who provided information (specify)

Signs and symptoms (in chronological order from the time of vaccination)

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**Instructions - Attach copies of ALL available documents (including case sheets, discharge summary, case notes, lab and autopsy reports) and then complete additional information NOT AVAILABLE in existing documents, i.e
• If patient has taken medical care - attach copies of all available documents (including cases sheet, discharge summary, laboratory reports and post mortem reports, if available) and write only information unavailable in the attached documents below

• If patient has not taken medical care - obtain histroy, examine the patient and write down your findings below (add additional sheets as required)

Name of person filling up clinical details given below

Designation

Date

Time

Consciousness

Alert Drowsy Unconscious Other

Vitals

Pulse

Temperature

Respiratory rate

BP Systolic Value

BP Diastolic Value

Weight(in kg)

Weight(in gm)

Skin

NAD Rash Cyanosis Petechiae Pallor Jaundice Others

Eyes

Vision:
Normal Impaired

Pupil
Normal Constricted Dilated Reacting to light

Hearing

Normal Impaired

Speech

Normal Abnormal

Neck

Neck stiffness
Present Absent

Chest

Auscultation:
Normal Crepts Rhonchi

Heart sounds
Normal Murmur

Respiration

Normal Cough Shortness Of Breath Others

GI

NAD Pain abdomen Vomiting Diarrhoea Dysentery Others

Abdomen

Normal Distended Tender

Liver
Not palpable Palpable

Spleen
Not palpable Palpable

Limbs

Tone

Upper Limbs
Normal Increased Decreased

Lower Limbs
Normal Increased Decreased

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Reflexes

Biceps
Normal Increased Decreased Absent

Triceps
Normal Increased Decreased Absent

Supinator
Normal Increased Decreased Absent

Plantar
Extensor Flexor

Any other abnormal signs

Treatment provided

Provisional Diagnosis *

(Please consult DIO for this information if not available in this form)

Section D - Details of vaccines provided on VACCINATION DAY at the site linked to AEFI

Number immunized for EACH VACCINE AT SESSION SITE. Attach record if available. Vaccine name

No of doses administered

Vaccine name

No of doses administered

Vaccine name

No of doses administered

1

When was the patient immunized? ( ✔ the ❒ below and respond to All questions )

Within the first vaccinations of the session Within the last vaccinations of the session Unknown

2

In case of multi-dose vials, was the vaccine given -

Within the first few doses of the vial administered Within the last doses of the vial administered Unknown

3

Based on your investigation, is it possible that: (please provide explanation for any 'Yes' answer in the remark column)

A

There was an error in prescribing or non-adherence to recommendations for use of this vaccine?*

Yes No Unable to assess

Vaccine/diluent name	Site of collection	Used vial/amp quantity	Batch no, Lot no,date of expiry	Date sent	Unused vial/amp quantity	Batch no, Lot no,date of expiry	Date sent

Type of syringes	Quantity	Site of collection	Batch no, Lot no,date of expiry	Date sent	Type of needles	Quantity	Batch no, lot no,date of expiry	Date sent

Ser No.	List of document copies received	Availability (encircle)
1.	Case reporting form (CRF)	Yes No
2.	Post mortem report
2A.	Post mortem report preliminary	Yes No
2B.	Post mortem report Final	Yes No
3.	Verbal autopsy form (in case of sudden unexplained death)	Yes No
4.	Any pathology/microbiology test report
4A	Blood test report	Yes No
4B	CSF report	Yes No
4C	Urine test report	Yes No
5.	Doctor's prescription/treatment record for AEFI	Yes No
6.	Doctor's prescription/treatment record for other illness	Yes No
7.	Laboratory result of vaccine (if sent for testing)	Yes No
8.	Laboratory result of syringes/other drugs (if sent for testing)	Yes No
9.	Any other document relevant to the case	Yes No

Sr No.	Name	Designation	Phone#	Signature
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Choose File	Upload	Name	Uploaded On	Delete

Case Data Entry

Case ID: Case ID

PRELIMINARY CASE INVESTIGATION FORM

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Criteria & Finding

Remarks (if "Yes" provide details)

If patient is an infant, birth details

Any birth complication(specify)

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Vision:

Pupil

Neck stiffness

Auscultation:

Heart sounds

Liver

Spleen

Tone

Upper Limbs

Lower Limbs

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Reflexes

Biceps

Triceps

Supinator

Plantar

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Details of vaccine/diluent samples sent to CDL Kasauli

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Details of syringe/needle samples sent to CDL Kolkata

Attached copies of reports/documents with this case investigation report

District AEFI committee that conducted the investigation

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PRELIMINARY CASE INVESTIGATION FORM | Upload scan of original PCIF

PRELIMINARY CASE INVESTIGATION FORM | Upload Other Supporting Documents

PRELIMINARY CASE INVESTIGATION FORM | Download System Generated PCIF

Number immunized for EACH VACCINE AT SESSION SITE. Attach record if available.	Vaccine name
	No of doses administered
	Vaccine name
	No of doses administered
	Vaccine name
	No of doses administered

Report	Choose File	Upload	Name	Uploaded On	Delete
Post Mortem Report Preliminary
Post Mortem Report Final
Verbal Autopsy Report
Blood Test Report
CSF Report
Urine test report
Doctor's prescription/treatment record for AEFI
Doctor's prescription/treatment record for other illness
Laboratory result of vaccine (if sent for testing)
Laboratory result of syringes/other drugs (if sent for testing)
Any other document relevant to the case