Case Data Entry

Case ID: Case ID

FINAL 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'.

Page 1

Name of investigator *

Date case visited and investigated *

Posted At *

Designation *

Date of preparing this form *

Time of preparing this form

Contact phone number *

E-Mail *

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 *

Pin No.

Phone #

Attached copies of reports/documents with the final case investigation report

** These options will be automatically populated as you upload the documents in Other supporting document section

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

Page 2

Date of vaccination *

Time of vaccination *

Address of session site *

Date first notified to govt. health system:

Notified by (please circle) *

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

Date of first symptom *

Time of first symptom *

Date of key symptom

Time of key symptom

Hospitalization *

Date of hospitalization

Time of hospitalization ( hh:mm AM/PM )

Name of hospital (if hospitalized)

Address of hospital (if hospitalized)

Current status *

If died, Date of death

Time of death

Post mortem done ?

If Yes, then give date postmortem done

If not done, but planned, give date planned

SECTION B : Refer to CRF,PCIF and updated information available for writing the case summary.Remember to include the following points,add additional sheet as necessary

Relevant information prior to immunization:

Status of immunization on the day AEFI reported(completed doses before the event):

Vaccines administered on the day of the event:

Post immunization event:

Page 3

Examination findings:

Laboratory findings:

Details of community investigation,if conducted:

Any other findings:

Treatment provided:

Post mortem report if available:

Provisional diagnosis: *

Page 4

SECTION C

Report of vaccine/diluent samples sent to CDL Kasauli

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

Report of syringe/needle samples sent to CDL Kolkata

Type of syringes	Quantity	Batch no, Lot no,date of expiry	Date sent	Lab finding	Type of needles	Quantity	Batch no, lot no,date of expiry	Date sent	Lab finding

Any biological product (CSF, blood, urine) sent for testing ?

Yes No

If "Yes", specify details of the lab; attach copy of report if available
Note: for AEFI resulting within 28 days following JE vaccine, send sample of CSF, serum to nearest NIV lab in Pune or Gorakhpur

Specify details of the lab.

Specify any other relevant investigations done and attach reports.

District AEFI committee meeting when case was discussed

Sr No.	Name	Designation	Phone#	Signature
1
2
3
4
5
6
7

SECTION D : DIO/district nodal person(Officer forwarding this report)

Name

Designation

Date of submission to state/national level

Mobile No

Landline(with STD code)

Fax No

E-Mail Id

Complete office address(with Pin code)

Signature and seal

Date

Please ensure that this investigation form reaches within 70 days of notification to:
1. State Immunization Officer
2. Deputy commissioner, Immunization Division of Govt of India, MoHFW, Niraman Bhavan, New Delhi-110108
(Fax: 011 23062728. email: aefiindia@gmail.com)

FINAL CASE INVESTIGATION FORM | Upload scan of original FCIF

Scanned FCIF and Documents

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FINAL CASE INVESTIGATION FORM | Upload Other Supporting Documents

Scanned Other Supporting Documents

Report	Choose File	Upload	Name	Uploaded On	Delete
Post mortem report preliminary
Post mortem report final
Verbal autopsy form (in case of sudden unexplained death)
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

FINAL CASE INVESTIGATION FORM | Download System Generated FCIF

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