FORM 2
Community / School Summary Form for treatment of household and Community Contacts with Azithromycin

State/Territory__________________________________________________________

Population Health Unit Region______________________________________________

Community/school_______________________________________________________

Date(s) of Screening ____________________________________________________

Form Completed by Name___________________________________ Date _________

Date of first treatment___________________________________________________

Treatment Strategy(Tick one box only)
The treatment strategies are based on CDNA Guidelines recommendations

Prevalence>10% in children

___ No obvious clustering in the community
Treatment Strategy: Treat all Aborginial children in the community aged 6 months - 14 years and all household contacts aged 6 months and over

___Cases obviously clustered in several households in the community and all household contacts are easily identified
Treatment Strategy: Treat all household contacts aged 6 months and over (community wide treatment not required)

Prevalence<10% in children

___Prevalence<10% but >5%
Treatment Strategy:Treat all household contacts aged 6 months and over

___Prevalence<5%
Treatment Strategy:Treat all household contacts aged 6 months and over

Number of contacts

<1 year1-4 year5-9 years10-14 years15+ years
Requiring treatment with azithromycin
Treated with azithromycin within two weeks of starting distribution of treatment
Total treated with azithromycin
Completion date of last treatment___________________________________________