CDC's Division of Parasitic Diseases and Malaria uses this form to record malaria cases diagnosed in the United States. A clinician meets it after diagnosing malaria, usually when the health department collects the case details. Part I covers lab results, travel, chemoprophylaxis, complications and treatment, and Part II, completed 4 weeks after treatment, records adherence, recurrence and adverse events.
The treating physician or health department staff complete Parts I and II and the submitter block, with extra physicians, hospital stays and tests on the continuation page. The state supplies the local record and subject IDs.
Download the current version from the source each time; forms change without notice.
Malaria Case Surveillance Report
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CDC's instructions say not to print or fax the form, because a paper copy cannot be processed electronically. Submit the fillable PDF by secure email to CDC or to your local or state health department. If electronic submission is not possible, CDC's Malaria Branch can be contacted for help.
Four weeks after treatment. Part II asks whether treatment was taken as prescribed, whether symptoms resolved within 7 days without more treatment, whether symptoms recurred within 4 weeks, and whether adverse events occurred. If they did, list all medications taken 2 weeks before and 4 weeks after starting malaria treatment.
Whether chemoprophylaxis was used and which drugs, such as atovaquone-proguanil, doxycycline, mefloquine, chloroquine, primaquine or tafenoquine; whether doses were missed; and why, for example forgetting, side effects or stopping once home. It also asks about any malaria in the previous 12 months and the species.