“SIRI”

JAMHURI YA MUUNGANO WA TANZANIA

WIZARA YA AFYA, MAENDELEO YA JAMII, JINSIA, WAZEE NA WATOTO

MFUMO WA TAARIFA ZA UENDESHAJI WA HUDUMA ZA AFYA

MTUHA TOLEO LA TATU: MWAKA 2018

FOMU YA TAARIFA YA KITABU CHA 14: REJESTA YA WAGONJWA WA KULAZWA (IPD)

Jina la Kituo.............................................................................. Wilaya.................................................................................

Tarehe ya Kuanza...................................................................... Tarehe ya Kumaliza.............................................................

 Taarifa ya Mwezi kutoka Wodini (IPD)
Jina la Kituo .................................................................................................... Wilaya......................................................... Mkoa............................................................... Mwezi ....................................................... Mwaka......................
Umri mwezi 1 hadi Umri mwaka 1 hadi Umri Miaka 60 Umri mwezi 1 hadi Umri mwaka 1 hadi Umri Miaka 60
JUMLA JUMLA
Na. Ugonjwa Umri chini ya mwezi 1 umri chini ya umri chini ya miaka Umri chini ya miaka na zaidi Na. Ugonjwa Umri chini ya mwezi 1 umri chini ya umri chini ya miaka Umri chini ya miaka na zaidi
KUU KUU
mwaka 1 5 60 mwaka 1 5 60
ME KE Jumla ME KE Jumla ME KE Jumla ME KE Jumla ME KE Jumla ME KE Jumla ME KE Jumla ME KE Jumla ME KE Jumla ME KE Jumla
1 Walolazwa Wodini 47 Hypetension, severe
2 Acute Flacid Paralysis 48 Other febrine illinesses
3 Cholera 49 Cardiovascular Disorders, Other
50 Bronchial Asthma, Severe
4 Dysentery
51 Upper Respiratory Infections
5 Measles (Pharyngitis, Tonsillitis, Rhinitis)
6 Meningitis 52 Pneumonia
7 Tetanus, Neonatal 53 Pneumonia, Severe
8 Plague 54 Peptic ulcers
55 Liver diseases, Non-infectious
9 Relapsing Fever
56 Gastrointestinal diseases,
10 Typhoid Other Non-infectious
11 Diarrhea, Acute (< 14 days) 57 Urinary Tract Infections (UTI)
12 Diarrhea, Chronic (> or = 14 days) 58 Nephrotic Syndrome
Malaria, Positive 59 Acute glumerulomephritis
13 Severe / (Bs/mRDT) 60 Renal failure
Complicated Clinical (no test)
61 Skin Infections
62 Skin Diseases, Non-infectious
14 Schistosomiasis
63 Osteomyelitis
15
STI Genital Discharge
Syndrome (GDS) 64 Rheumatoid and Joint diseases
65 Low birth weight and
16 STI Genital Ulcer Diseases (GUD)
Prematurity complications
17 STI Pelvic Inflammatory diseases (PID) 66 Birth asphyxia
67 Neonatal Septicaemia (Local infections)
18 Sexually Transmitted Infection, Other 68 Road Traffic Accidents
19 Ectopic Pregnancy 69 Fractures
20 Abotion Complication 70 Poisoning
71 Burns
21 Gynaecological diseases, Other 72 Animal Bites (Suspected Rabies)
22 Tuberculosis 73 Animal Bites (No suspected rabies)
23 Leprosy 74 HIV infection, Symptomatic
24 Diabetes 75 Congenital Disorders
25 Kwashiorkor 76 Hepatitis
26 Marasmus 77 Malignant neoplasm of breast
27 Marasmic - kwashiorkor 78 Malignant neoplasm of female genital organs
28 Moderate Malnutrition 79 Malignant neoplasm of digestive organs
29 Nutritional Disorders, Other 80 Malignant neoplasm of male genital organs
30 Thyroid Diseases 81 Neoplasm /cancer, others
31 Sickle cell Disease 82 Hernia
32 Haemotoloogical Disorder 83 Abscess
33 Anaemia, Mild / Moderate 84 Goiter
34 Anaemia, Severe 85 Intestinal Obstruction
35 Psychoses 86 Appendicitis
36 Neuroses 87 Surgical Conditions, others
37 Substance abuse 88 Soil transmitted helminthes
38 Cerebral Palsy 89 Lymphatic filairiasis
39 Epilepsy 90 Anthrax
40 Ear Diseases, non-infectious 91 Viral haemorrhagic fever
41 Ear infection, Acute 92 Diagnoses, Other
42 Ear Infection, Chronic 93 Deaths
43 Eye diseases, Infections, 94 Waliotibiwa kwa Bima ya Afya
44 Eye diseases, Non-infectious 95 Waliotibiwa kwa pesa taslim (cash)
45 Eye diseases, Injuries
96 Waliotibiwa kwa Msamaha
46 Cardiac failure

Jina la Mtayarishaji wa Ripoti ........................................................................................... Cheo..........................................Wadhifa .................................... Tarehe ya kuandaa........../....../............ Imepitiwa na .......................................................................................

Namba ya simu ya kituo............................................... Taarifa imepokelewa wilayani tarehe............./.........../.................