Avian influenza outbreak investigation form – COMMERCIAL flocks
Unique ID ____________________________ (one form per commercial unit investigated)
GENERAL INFORMATION
Reason for visit
Central request Provincial request District request Repeat visit1
Name of Investigator (cellphone number & email
Title of Investigator Date of this visit
1: If a repeat visit use the original unique record number
LOCATION
Name of owner / manager
Province District Sub District
Village Sub Village
GPS of commercial unit Northing Easting
BIRDS ON SITE (current numbers/ages, i.e. 1,000/26 weeks old)
Layers Broilers Native chickens Ducks
Healthy
Sick Dead due to illness
Culled
Muscovy
Ducks Geese Healthy Sick Dead due to illness
DESCRIBE DISEASE EVENT (start approximately 2 weeks before first death/sign)
CLINICAL SIGNS CHECKLIST
Body system Presence Duration Describe
Gastrointestinal Nervous Musculoskeletal Feathers / comb / skin Sudden death Other
VACCINATION HISTORY
Type Manufacturer Ekor Who vacc? Age when vaccinated
1st 2nd 3rd 4th 5th
e.g.AI Medion 1,000 Owner 10 days 16 weeks 20 weeks 46 weeks
HOUSING SYSTEM
Chickens Ducks Other Deep litter
Cage system Bird proof nets Free range Other
Number of houses on site Total Affected
VENTILATION SYSTEM
Chickens Ducks OTHER
Natural Only OPEN HOUSE Natural Only CLOSED HOUSE Natural fan assist
Controlled climate
SOURCE OF BIRDS
Chickens Ducks OTHERS
Hatchery Rearer Dealer Other
DIAGNOSTIC TESTS
Rapid antigen test result
Number of tests Number positive Number negative
Type of rapid antigen test
Laboratory samples submitted
Carcass Blood/serum Cloacal swab Oropharyngeal swab Environmental swab Other
Laboratory tests requested HPAI PCR Virus isolation HPAI serology
Bacteriology Anatomic pathology Toxicology
Date samples submitted
Laboratory accession form number (retrospective information) Laboratory case diagnosis (retrospective information)
RISK FACTORS (from approximately 7 days from first mortality)
Risk factor Risk existing1 High risk1 Visit from poultry collectors
Visit from egg collectors Birds received from markets
Nearby rice field grazed by commercial ducks flocks Contact with village ducks
Contact with village chickens Farm vehicles/equipment ? Feed delivered
Infected premises <=1km (household or commercial) Vaccination team visit
Veterinary/para-veterinary visit Large flocks of wild birds near village
Visit by professional agriculture worker (vet, farm adviser etc)
Other Other Other Other
MAP OF FARM SITUATION (show key risk factors such as other infected places,
markets, rivers, etc).
HUMAN CASES IN VILLAGE
Age Sex Date of
symptoms Recovered (Y/N) Date of death Occupation
HIGH RISK TRACES ON (since 7 days before clinical signs)
High risk trace on Date NO. Source
HIGH RISK TRACES OFF (since clinical signs)
Form Investigasi Wabah Avian Influenza (AI)
Informasi Umum
Asal Informasi
Pusat Provinsi Kabupaten Repeat visit1
Nama Investigator (HP & email) Title of Investigator Tanggal Kunjungan
1: If a repeat visit use the original unique record number
LOKASI KEJADIAN
Nama Pemilik Provinsi Kabupaten Kecamatan Desa Dusun/ RT/ RWGPS of commercial unit Northing Easting
BIRDS ON SITE (current numbers/ages, i.e. 1,000/26 weeks old)
Layers Broilers Ayam
Kampung Unggas Air Sehat Sakit Mati karena sakit
Culled (dimatikan)
Muscovy
Ducks Geese Sehat Sakit Mati dikarenakan sakit
Gambaran Kejadian Penyakit (Dimulai 2 minggu sebelum kematian/ sakit pertama)
CLINICAL SIGNS CHECKLIST
Sistem Presence Lama Kejadian Gambaran
Gastrointestinal Nervous Musculoskeletal Feathers / comb / skin Sudden death Other
Sejarah Vaksinasi
Type Manufacturer Ekor Who vacc? Age when vaccinated
1st 2nd 3rd 4th 5th
e.g.AI Medion 1,000 Owner 10 days 16 weeks 20 weeks 46 weeks
Sistem Pemeliharaan
Ayam Unggas Air Lainnya
Deep litter Cage system Bird proof nets Free range Other
Number of houses on site Total Affected
VENTILATION SYSTEM
Chickens Ducks OTHER
Natural Only OPEN HOUSE Natural Only CLOSED HOUSE Natural fan assist
Controlled climate
SOURCE OF BIRDS
Chickens Ducks OTHERS
Hatchery Rearer Dealer Other
DIAGNOSTIC TESTS
Rapid antigen test result
Number of tests Number positive Number negative
Type of rapid antigen test
Laboratory samples submitted
Carcass Blood/serum Cloacal swab Oropharyngeal swab Environmental swab Other
Laboratory tests requested HPAI PCR Virus isolation HPAI serology
Bacteriology Anatomic pathology Toxicology
Date samples submitted
Laboratory accession form number (retrospective information) Laboratory case diagnosis (retrospective information)
RISK FACTORS (7 hari sebelum kematian pertama)
Risk factor Risk existing1 High risk1 Kunjungan pengepul ayam
Kunjungan pengepul telur
Datangnya ayam/ unggas air dari pasar Dekat dengan sawah yang ada unggas airnya Kontak dengan unggas air (entog)
Kontak dengan ayam kampung sekitarnya Peralatan kandang
Pengantar pakan
Peternakan terinfeksi<=1km (backyard atau komersial) Kunjungan vaksinator
Kunjungan dokter hewan dan paramedis
Peternakan komersial yang dekat dengan kampung Kunjungan anak kandang
Apakah letak peternakan dekat dengan sungai ?
PETA SITUASI PETERNAKAN ( Daerah terinfeksi, pasar, sungai, dll).
Kejadian pada manusia di kampung disekitarnya
Umur Sex Tanggal
Kejadian Recovered (Y/N) Tanggal Kematian Pekerjaan
HIGH RISK TRACES ON (since 7 days before clinical signs)
High risk trace on Date NO. Source
HIGH RISK TRACES OFF (since clinical signs)
Form Investigasi Wabah Avian Influenza (AI)
(Sektor III/ IV)
Informasi Umum
Asal Informasi
Pusat Provinsi Kabupaten Repeat visit1
Nama Investigator (HP & email) Title of Investigator Tanggal Kunjungan
1: If a repeat visit use the original unique record number
LOKASI KEJADIAN
Nama Pemilik Provinsi Kabupaten Kecamatan Desa Dusun/ RT/ RWGPS of commercial unit Northing Easting
BIRDS ON SITE (jumlahnya/ umur, contoh: 1,000/26 weeks old)
Ayam Petelur Broilers Ayam
Kampung Unggas Air Sehat Sakit Mati karena sakit
Culled (dimatikan)
Muscovy
Ducks Geese Sehat Sakit Mati dikarenakan sakit
Gambaran Kejadian Penyakit (Dimulai 2 minggu sebelum kematian/ sakit pertama)
CLINICAL SIGNS CHECKLIST
Sistem Presence Lama Kejadian Gambaran
Gastrointestinal Nervous Musculoskeletal Feathers / comb / skin Sudden death Other
Sejarah Vaksinasi
Type Manufacturer Ekor Who vacc? Age when vaccinated
1st 2nd 3rd 4th 5th
e.g.AI Medion 1,000 Owner 10 days 16 weeks 20 weeks 46 weeks
Sistem Pemeliharaan
Ayam Unggas Air Lainnya
Deep litter Cage system Bird proof nets Free range Other
Number of houses on site Total Affected
VENTILATION SYSTEM
Chickens Ducks OTHER
Natural Only OPEN HOUSE Natural Only CLOSED HOUSE Natural fan assist
Controlled climate
SOURCE OF BIRDS
Chickens Ducks OTHERS
Hatchery Rearer Dealer Other
DIAGNOSTIC TESTS
Rapid antigen test result
Number of tests Number positive Number negative
Type of rapid antigen test
Laboratory samples submitted
Carcass Blood/serum Cloacal swab Oropharyngeal swab Environmental swab Other
Laboratory tests requested HPAI PCR Virus isolation HPAI serology
Bacteriology Anatomic pathology Toxicology
Date samples submitted
Laboratory accession form number (retrospective information) Laboratory case diagnosis (retrospective information)
RISK FACTORS (7 hari sebelum kematian pertama)
Risk factor Risk existing1 High risk1 Kunjungan pengepul ayam
Kunjungan pengepul telur
Datangnya ayam/ unggas air dari pasar Dekat dengan sawah yang ada unggas airnya Kontak dengan unggas air (entog)
Kontak dengan ayam kampung sekitarnya Peralatan kandang
Pengantar pakan
Peternakan terinfeksi<=1km (backyard atau komersial) Kunjungan vaksinator
Kunjungan dokter hewan dan paramedis
Peternakan komersial yang dekat dengan kampung Kunjungan anak kandang
Apakah letak peternakan dekat dengan sungai ?
PETA SITUASI PETERNAKAN ( Daerah terinfeksi, pasar, sungai, dll).
Kejadian pada manusia di kampung disekitarnya
Umur Sex Tanggal
Kejadian Recovered (Y/N) Tanggal Kematian Pekerjaan
HIGH RISK TRACES ON (since 7 days before clinical signs)
High risk trace on Date NO. Source
