CBHI Form No. 02
Monthly
MONTHLY REPORT ON INSTITUTIONAL CASES AND DEATHS DUE TO
PRINCIPAL COMMUNICABLE DISEASES IN THE STATE/UT
NAME OF THE STATE/UT          
REPORTING MONTH & YEAR      
Total No. of Medical     Total No. of Medical Care Institution reported during the month    
Care Institutions in the State/UT$        
                       
Sl. No. Name of Disease as per standard Patients Treated Deaths
definition of case ICD - 10 OPD* IPD* Total (IPD Only)
  code M F M F M F M F T
1 Acute Diarrhoeal Diseases** A09                  
  (including Gastro Enteritis Etc.)                    
2 Diphtheria A36                  
3 Acute Poliomyelitis (New listed cases) A80                  
4 Tetanus other than Neonatal A35                  
5 NeoNatal Tetanus A33                  
6 Whooping Cough A37                  
7 Measels B05                  
8 Acute Respiratory Infection J22                  
  (including Influenza and excluding Pneumonia)                    
9 Pneumonia J18                  
10 Enteric Fever A01                  
11 Viral Hepatitis - A B15.9                  
12 Viral Hepatitis - B B16.9                  
13 Viral Hepatitis - C,D, E B17.8                  
14 Meningococcal Meningitis A39.0                  
15 Rabies *** A82                  
16 AIDS (as reported to NACO) B24                  
17 Syphilis A50-A53                  
18 Gonococcal Infection A54                  
19 Other STD Diseases A63-A64                  
20 Pulmonary Tuberculosis A16.2                  
  TOTAL                    
*IPD-In-Patient       OPD-Out-Patient  M-Male,    F - Female,   T-Total
The report for every month should be dispatched to CBHI by 20th of the succeeding month through e-mail dircbhi@nb.nic.in
NOTES:
$ All the medical institutions i.e. Hospitals, Dispensaries, Clinics, PHCs, CHCs, Sanatoria etc. to be covered
The cases and deaths due to various diseases other than those treated in Medical Institutions, whenever reported / recorded should also be included in this report
** Acute diarrhoeal disease should include all Gastro Enteritis cases i.e. cases with three or more loose watery
motions in a day, irrespective of aetiology / causation
*** Only confirmed cases of Rabies i.e. Hydrophobia should be included and not the simple dog-bite/animal bite cases
 Data on vaccine preventable disease should tally with Universal Immunization Program (UIP) data being furnished by
State EPI (Extended Program of Immunisation) officer to Min. of Health & FW
**********
To
The Director
Central Bureau of Health Intelligence (CBHI)
Room No. 401 - A Wing, Nirman Bhavan
New Delhi 110011
E-Mail: dircbhi@nb.nic.in
Tel/ Fax: 91-011-23793175 / 23017695
  Signature          
 Name & Designation        
Address with Tel/Fax & E-Mail