Daily Hospital Surveillance Reporting for (Date) Do you wish to select a health facility code? Yes yes No no Health Facility Select From List A Hospital 1111111111 B Hospital 1111111112 C Hospital 1111111114 D Hospital 1111111116 Other other Specify Facility Code 10 digits All new medical, pediatric, and general OPD, and Emergency patients treated New patients under 5 years New patients 5 years or above All new epidemic prone cases in medical, pediatric, and general OPD, and Emergency Influenza Like Illness under 5 years Influenza Like Illness 5 years or above All new epidemic prone cases in medical, pediatric, and general OPD, and Emergency Severe Acute Respiratory Infection under 5 years Severe Acute Respiratory Infection 5 years or above All new epidemic prone cases in medical, pediatric, and general OPD, and Emergency Acute Watery Diarrhoea under 5 years Acute Watery Diarrhoea 5 years or above All new epidemic prone cases in medical, pediatric, and general OPD, and Emergency Acute Bloody Diarrhoea under 5 years Acute Bloody Diarrhoea 5 years or above Suspected Cholera 5 years or above only All new epidemic prone cases in medical, pediatric, and general OPD, and Emergency Fever with Jaundice under 5 years Fever with Jaundice 5 years or above All new epidemic prone cases in medical, pediatric, and general OPD, and Emergency Fever with Rash under 5 years Fever with Rash 5 years or above All new epidemic prone cases in medical, pediatric, and general OPD, and Emergency Fever without rash and jaundice under 5 years Fever without rash and jaundice 5 years or above If you suspect any potential outbreak or need any additional support Please call: 1234567890 4567890123 Or email: help@example.com help2@example.com