TO BE FILLED OUT BY UTVE

Weekly / Monthly *

Date: __ __ __ __-__ __-__ __

_____________

(year-month-day)

(authorized signature)

TO BE FILLED OUT BY THE REPORTING PHYSICIAN

Period (from - to):

Month:

Form to be send by internal mail and by fax to UTVE (533524)

Year:

TO BE FILLED OUT BY THE REPORTING PHYSICIAN, IN CAPITALS

Name (roman characters):

Address:

Telephone:

1.1 Number of AFP cases seen in children less than 15 years of age, during this reporting period (circle or write which apply):

0  –  1  –  2  –  3  –  4  ____

1.2 If any cases, where and when have been they send:

2.1 Number of AFP cases seen in children less than 15 years of age, during the previous reporting period (circle or write which apply):

0  –  1  –  2  –  3  –  4  ____

2.2 If any cases, where and when have been they send:

3. Number of AFP cases seen during this month/year** (circle or write which apply):

0  –  1  –  2  –  3  –  4  ____

Notification date:

Signature:

Remarks:

* please cut which do not apply (weekly or monthly)

** please cut which do not apply (month or year)

- Note for reporting key physicians in all health care units (health centres and hospitals): please send immediately this form by fax to UTVE (fax: 533524), when a AFP case is detected.