End of Ebola outbreak reporting survey form

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Form ID ?

End_of_Ebola_outbreak_report

Version ? Standard mode

Automatic ID ? Standard mode

Default Language ? English

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http://kobotoolbox.org/data/longish_username

Public Key ? 12345-232

End of Ebola outbreak report

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1. What date is it at the time of reporting?

2. What is the name of the reporting officer?

UNHCR

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Implementing partner

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3. What is the title of the reporting officer?

Health coordinator

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Medical coordinator

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Surveillance officer

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4. What is the name of the organization where the officer works?

Oxfam

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Save the Children

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Medicines Sans Frontieres (MSF)

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World Vision International (WVI)

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United Nations Children's Fund (UNICEF)

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International Federation of Red Cross

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Save the Children

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5. In which country has the outbreak been declared?

Liberia

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Sierra Leone

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Guinea

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Nigeria

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Senegal

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6. What locations or camps were affected by the outbreak?

Alpha Yaya

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Bourora

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Cabinet de Soins

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Centre de Sante Boke Centre

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Bahn

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Bar Ta Clinic

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Botota Clinic

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Clara Town

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Diamei

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Durukoro

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Guala

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Kalangba

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Mopti

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Kuolikoro

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Segou

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Sikasso

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Joe Jane Medical Center

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Odo Ado Medical Center

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Grace of Hope Hospital

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Adedoyin Hospital

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Centre Hospitalier Regional de Saint-Louis du Senegal

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Dakar Cardiology Center-Senegal

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7. What is the type of outbreak encountered?

Cholera

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Measles

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Meningitis

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Ebola

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Bird flu

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Typhoid fever

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Malaria

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8. What was the date and the epidemiological week the outbreak first started?

9. What was the date and the epidemiological week the outbreak was officially declared over?

10. Was the diagnosis confirmed by the laboratory?

Yes

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No

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11. What was the total number of cases encountered?

12. What was the total number of deaths confirmed as a result of the outbreak?

13. What was the attack rate?

14. What was the case fatality rate?

15. Please select the criteria which describes the persons, place and time of outbreak: