Government of Nepal

Ministry of Health and Population

DoHS, EDCD
Disease Recording/Reporting Form

Hospital Name
Email ewarsedcd@gmail.com
Current Address
Nepali Date Registration Remarks
SN OPD/Eme/IPD Disease Diagnosed Name of Patient Age Sex District Municipality Ward No Village/Tole Contact No
[yyyy-mm-dd] No

1
2076-04-22 Year

2
Year

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24
 EWARS Summary Report

Report for Week 1 to 52 of 2019

Age and Sex Wise Distribution Outcome
Under Total
<1 Year 1 - 4 Years 5 - 14 Years 15 + Years Total Cured Death Referred Treatment LAMA Others Improved
SN Diseases Male Female Male Female Male Female Male Female M F M+F
4 Dengue ### ### ### ### ### ### ### ### ### ### #NAME? #NAME? #NAME? #NAME? #NAME? ### ### #NAME? #NAME?
 Instructions for filling the form
Sentinel Site Name List of Sentinel site is provided, select your site.
Email Contacts where this report is to be sent periodically (weekly)

Form Fields to be filled

SN Enter the serial number

Nepali Date Nepali date (BS) of the patient registration, please type Year-month-day (eg: 2015-10-16)

The epidemiological week number which the patient is registered. List is provided, please
Week No
select.
Reg. No Enter the hospital registration number of the patient.

OPD/Eme/IPD Please select type of patient registration (OPD/IPD/Emergency).

Name of Patient Enter full name of the patient

Age of the patient, please type whole number
Age
Select Year or month or day for patient age.
Sex Select sex of the patient.
District District, Select from the list.
VDC/Muni VDC/Municipality, select from the list.
W.No Address of the patient Ward number, select from the list.
Village/Tole Type the name of village or tole
Contact No Type the contact number of patient
Disease Name Name of the disease, select from the list.

ICD Code Disease which the ICD code associated with the disease, automatically populated.
patient was diagnosed
If Other, Specify Type the disease name if others is selected in previous cell.

Diagnosis Type of diagnosis, select among probable, confirmed and suspect.

Method Method of the diagnosis, select from the list.
Result Lab report Result of the lab test, select from the list.
Place Place/Lab name where the test was performed.
Outcome Select the outcome.
If Referred, Outcome If the outcome is 'referred', type the name of the health facility
Location/Institution where the patient was referred.
 Instructions for Report

Select the range of weeks which you want to calculate the report. Week from is always
Week range smaller or equal to the week to.

Color Indicators

Orange
In the form, the cell with this color indicates that some data is expected, when you type the
required information the color disappears. If the outcome is 'Under Treatment', it indicates
that this value should change later as per treatment result. In the report completeness
indicator this color means that the data completeness is between 21% to 79% (Satisfactory).

Green
This color at the end of each row of the form indicates that data for the row is complete. In
the completeness indicator, it indicates that the data completeness is equat or more than
80% (Excellent).

Red

This color at the end of each row of the form with 'Incomplete Data' label, indicates that the
data for this row is incomplete, check if data entry is missing. In the report completeness
indicator, this means that the completeness of the report is less than 20% (Poor).

For Further Support please contact Epidemiology and Disease Control Division, Teku, Kathmandu.
Contact Person : Mr. Niraj Thapa, Padam Dahal
Phone: 01-4255796 (Office), 9841427571 (Niraj), 9841781438 (Padam)
Email: ewarsedcd@gmail.com, ewarsnepal@gmail.com