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Transcript
FORM 2
PREVENTION AND CONTROL OF DISEASE ORDINANCE
(Cap. 599)
Notification of Infectious Diseases other than Tuberculosis
Particulars of Infected Person
Name in English:
Name in Chinese:
Age / Sex:
Residential address:
I.D. Card / Passport No.:
Telephone No.
(Home):
(Mobile):
Name and address of workplace / school:
(Office / school / others):
Job title / Class attended:
Hospital / Clinic sent to (if any):
Hospital / A&E No.:
Disease [“”] below Suspected / Confirmed on ______ / _______ / _________ (Date: dd/mm/yyyy)
□
Acute poliomyelitis
□
Amoebic dysentery
□
□
□
Anthrax
□
Hantavirus infection
□
Scarlet fever
□
Bacillary dysentery
□
Invasive pneumococcal disease
□
Severe Acute Respiratory
□
Botulism
□
Japanese encephalitis
□
Chickenpox
□
Legionnaires' disease
□
Chikungunya fever
□
Leprosy
□
Cholera
□
Leptospirosis
□
Smallpox
□
Community-associated methicillin-resistant
□
Listeriosis
□
Streptococcus suis infection
Staphylococcus aureus infection
□
Malaria
□
Tetanus
□
Creutzfeldt-Jakob disease
□
Measles
□
Typhoid fever
□
Dengue fever
□
Meningococcal infection (invasive)
□
Typhus and other rickettsial
□
Diphtheria
□
Middle East Respiratory Syndrome
□
Enterovirus 71 infection
□
Mumps
□
Viral haemorrhagic fever
□
Food poisoning
□
Novel influenza A infection
□
Viral hepatitis
Number of persons known to be affected:
□
Paratyphoid fever
□
West Nile Virus Infection
Place and district of consumption
(e.g. “XX Restaurant in Mongkok”):
□
Plague
□
Whooping cough
□
Psittacosis
□
Yellow fever
□
Q fever
□
Zika Virus Infection
□
Rabies
□
Relapsing fever
Haemophilus influenzae
type b infection (invasive)
Rubella and congenital
rubella syndrome
Syndrome
□
Shiga toxin-producing
Escherichia coli infection
diseases
Date of consumption:
Notified under the Prevention and Control of Disease Regulation by
Dr. ______________________________ of ___________________________Hospital / Clinic / Private Practice
(Full Name in BLOCK Letters)
____________________________Ward / Unit / Specialty on ______ / _______ / ________ (Date: dd/mm/yyyy)
Telephone No.: ________________
Remarks:
DH 1(s)(Rev. February 2016)
Fax No.: ___________________
___________________________
(Signature)