Download Notification of Infectious Diseases Form

CONFIDENTIAL—Notification of Infectious Disease
Health (Infectious Diseases) Regulations 2001, Schedule 4 (2000/0030200)—Version 2, May 2001
Diseases marked (whether presumptive or confirmed) require immediate notification by
telephoning 1300 651160. All notifications must be sent within five (5) days of diagnosis to:
Communicable Diseases Section, Human Services, Reply Paid 65937, Melbourne VIC 8060
or fax 1300 651170 (1300 calls are charged at local call cost).
Disease to Notify
Case Details
Completion of some questions for sexually transmitted infections (STIs) is not required. These are indicated below.
Patient Surname
For STIs, include first two letters of first name only
First Name(s)
Postcode is required for ALL diseases
Botulism
Brucellosis
Campylobacteriosis
Chlamydia trachomatis genital infection (STI)
Cholera
Cryptosporidiosis
Diphtheria
Donovanosis (STI)
Food or water borne illness (2 or more related cases)
Giardiasis
Gonococcal infection (STI)
Haemolytic uraemic syndrome (HUS)
Haemophilus influenzae type b infection (Hib)
Hepatitis A
Hepatitis B
Acute
Non-acute
Hepatitis C
Acute
Non-acute
Hepatitis D
Hepatitis E
Hepatitis viral (not further specified)
Influenza (laboratory confirmed)
Legionellosis
Leprosy
Leptospirosis
Listeriosis
Lyssavirus
Australian Bat lyssavirus
Malaria
Measles
Meningococcal infection
Mumps
Paratyphoid
Pertussis
Plague
Pneumococcal infection (invasive)
Poliomyelitis
Psittacosis (ornithosis)
Q fever
Rabies
Rubella
Congenital rubella syndrome
Salmonellosis
Shigellosis
Syphilis (STI)
Congenital
Early (<2 years)
Late (>2 years)
Tetanus
Tuberculosis
Typhoid
Vero-toxin producing Esherichia coli (VTEC)
Viral Haemorrhagic Fever
Yellow Fever
For STIs, include first two letters of surname only
Patient Residential Address (do not complete address for STIs)
City/Suburb/Town (do not complete city for STIs)
Postcode
Occupation and/or School and/or Child Care Attended (do not complete occupation for STIs)
Sex (gender)
Female
Male
Age (if birth date unknown)
Date of Birth
Years
Australian
arbo-encephalitis
Barmah Forest virus
Dengue virus
Flavivirus (other)
Japanese encephalitis
Kunjin virus
Ross River virus
Months
Tick below where applicable
Anthrax
Arbovirus Infection
(Please print clearly. Tick boxes where applicable).
Is the patient alive?
Alive
Deceased
Date of Onset of Illness
Is the patient of Aboriginal or Torres Strait Islander origin?
No
Yes, Torres Strait Islander
Yes, Both Aboriginal and Torres Strait Islander
Yes, Aboriginal
Clinical Comments (include any relevant comments, such as possible source of infection, others ill, etc.)
Notifying Doctor/Laboratory/Hospital Details
Name of Notifying Doctor, Laboratory or Hospital
Address
City/Suburb/Town
Telephone
DHS Use Only
Postcode
Signature
Date
Check:
3200
CC:
Requirements and Instructions for Notifying Cases of
Infectious Diseases within Victoria
Infectious diseases still occur frequently throughout the world, so constant vigilance is required to prevent
the reappearance of diseases thought to have been conquered. Changes in lifestyle have also led to the
emergence of new threats to public health from infection. Health authorities depend on medical practitioners
for information on the incidence of infectious diseases. Notification is vital in efforts to prevent or control the
spread of infection.
Notifiable Infectious Diseases are included in Schedule 3 of the Health (Infectious Diseases) Regulations 2001
and are divided into four groups on the basis of the method of notification and the information required.
With the exception of HIV/AIDS, these groups are all included on the enclosed form.
Group A Diseases require notification to the Department of Human Services by telephone or fax upon initial
diagnosis (presumptive or confirmed), with written notification to follow within five days. These diseases
are underlined on the form.
Group B Diseases require written notification only, within five days of diagnosis.
Group C Diseases include the sexually transmitted infections (indicated on the form as STIs) and should be
notified using the same form. To preclude identification of the patient, only the first two letters of the given
and family name of the patient are required.
Group D Diseases include HIV (Human Immunodeficiency-virus) and AIDS (Acquired Immunodeficiency
Syndrome) and written notification is required within seven days of confirmation of diagnosis. A separate
form is used for this purpose due to the need to have national uniformity in collection of data. Copies of this
form are forwarded to the diagnosing medical practitioner with the laboratory confirmation of HIV
infection.
The Department provides pre-printed Reply Paid envelopes (no stamps required) and STD toll free
telephone and facsimile numbers to make notifying as simple as possible. Copies of the form, information on
diseases and outbreaks, media releases, disease data and other publications are all available at the
Department of Human Services Internet site http://www.dhs.vic.gov.au
All notifications and related inquiries should be directed to:
Communicable Diseases Section, Public Health Division
Victorian Government Department of Human Services
Reply Paid 65937
Melbourne VIC 8060
Telephone 1300 651160
Facsimile 1300 651170
After Hours
Contact the Duty Medical Officer
via pager service 132222
and quote pager number 46870
Please retain a copy of the notification for your records.
Please PRINT clearlyThank you.
2000/0030200