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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)