FEVER SURVEILLANCE REPORT                                    (Body Temperature more than 98.6 F or 37 C)
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Important Note :- All Nodal Officers ensure that the necessary entries are made in the prescribed format and submit the same latest by 5 PM daily without fail.  Even if no cases are found, Nodal Officers are required to enter fields with NIL values in the given format. (Example Emp Name: Nil  Mobile no:0)
Employee Details:
1. DATE *
MM
/
DD
/
YYYY
 2 . Name of the Factory / Establishment with Address *
2(A)  Total No. of Employees *
2(B)  No. of Employees above 45 Years *
2(C)  No. of Employees Vaccinated *
2(D)  No. of Employees Scanned *
  2 (E)NODAL OFFICER NAME (NIL NOT ALLOWED) *
2 (F) NODAL OFFICER MOBILE NO   *
2 (G) SELECT INDUSTRY LOCATED TALUK NAME *
3. EMPLOYEE NAME (NAME IN CAPITAL & INITIAL AT THE END ) *
4. FATHER NAME  (NAME IN CAPITAL & INITIAL AT THE END ) *
5. Age *
6. Gender *
7.  Permanent Address   (DOOR NO & STREET NAME) *
7 (A)  VILLAGE NAME *
7(B) SELECT  TALUK NAME (EMPLOYEE ADDRESS) *
7(C) PINCODE *
8.  Mobile Number *
9. "Body Temperature (More than Normal Temperature of 98.6 F or 37 C)" *
10. Is there any Comorbidities (Diabetes, BP and other disease) ? *
11.  Date of occurrence of symptoms
MM
/
DD
/
YYYY
12.  Whether refered to Hospital or PHC *
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