FORM 1
Community / School Summary Form for Screening of Children for Active Trachoma

State/Territory_________________________________________________________

Population Health Unit Region______________________________________________

Community/school_______________________________________________________

Screening Strategy School___ Community___

Date(s) of Screening _____________________________________________________

Form Completed by Name_________________________________ Date ____________

Number of Aboriginal children:

1-4 years

5-9 years

10-14 years

Total number in community/school
Total number enrolled in school
Examined for trachoma and clean face*
With TF
With active trachoma (TF and /orTI)
With TS
With clean face*
Requiring azithromycin for active trachoma (TF and/orTI)
Received azithromycin for active trachoma (TF and/orTI) within 2 weeks of screening

* Defined as the absence of dirt, dust or crusting on the cheeks and forehead
TF: Trachomatous inflammation - Follicular
TI: Trachomatous inflammation - Intense
TS: Trachomatous - Scarring
Cased on Workd Health Organisation simplified frading classification system, Source: World Health Organisation, 1987