Infectious and Related Diseases Notification Form

1 Infectious and Related Diseases Notification Form20 Date received by DOH20 Notification IDYou may notify your Public Health Unitby post, telephone or faxFor urgent Diseases after hours: Phone (08) 9328 0553 PATIENT DETAILSF amily name Given name Street address Suburb/Town Postcode Tel. Home Mobile Date of birth / / dd mm yyyySex Male Female TransgenderCountry of birth Australia Other, specify Language spoken at home English Other, specify Occupation or name of school/childcare centre attended: Is the patient of Aboriginal and/or Torres Strait Islander origin?

2 No Yes, Aboriginal Yes, Torres Strait Islander(For persons of both Aboriginal and Torres Strait Islander origin, tick both yes boxes.) disease DETAILSHow was the infection identified? Clinical presentation Contact tracing Screening Date of onset / / Date of death / / dd mm yyyy (if applicable) dd mm yyyyPlace infection acquired WA Interstate Overseas UnknownIf acquired interstate/overseas, specify Was the patient hospitalised?

3 No Ye sHow was diagnosis made? Lab Result pending Linked to lab-confirmed case Clinical only Method: Result: FOLLOW-UP (tick one or more) Patient/carer aware of diagnosis and that it is a notifiable disease . Risk to contacts discussed with patient. Patient/carer aware Public Health Unit may contact them for information. Other CLINICAL COMMENTS (presentation, treatment)NOTIFIER DETAILSName .. Phone .. Clinic/Hospital .. Address .. Postcode ..Signature .. Date ../../.. dd mm yyyy NOTIFIABLE Diseases (tick box below) Pursuant to the WA Public Health Act 2016 please notify Diseases marked with a by telephone within 24 hours of diagnosis.

4 Otherwise fax or post Notification within 72 hours of organisms (MRSA, CRE, VRE) are notified by laboratories. Notification by doctors or nurse practitioners is not post-streptococcal glomerulonephritis (APSGN)Adverse event following immunisation use separate formAmoebic meningoencephalitisAnthraxBarmah Forest virus infectionBotulismBrucellosisCampylobacte r infection Species: ChancroidChikungunya virus infectionChlamydia Lymphogranuloma venereum (serovar L1-3 detected)CholeraCreutzfeldt-Jakob disease (classical or variant)CryptosporidiosisDengue virus infectionDiphtheriaDonovanosisFlavivirus infection JE MVE West Nile/Kunjin Yellow fever Zika OtherFood or water-borne gastroenteritis ( 2 linked cases)Gonococcal infectionHaemolytic uraemic syndrome (HUS)Haemophilus influenzae type b (Hib) infection (invasive)Hendra virus infectionHepatitis AHepatitis B newly acquired (<2 yrs) Chronic/unspecifiedHepatitis C newly acquired (<2 yrs)

5 Chronic/unspecifiedHepatitis (other) D EHIV infection use separate formInfluenza Legionellosis Longbeachae Pneumophila Other LeprosyLeptospirosisListeriosisLyssaviru s infection Rabies ABL Other Malaria Species: MeaslesMelioidosisMeningococcal infection Meningitis Septicaemia OtherMiddle East Respiratory Syndrome coronavirus (MERS-CoV)MumpsParatyphoid feverPertussisPlaguePneumococcal infection (invasive)Poliovirus infectionPsittacosis (ornithosis)Q FeverRheumatic fever/heart disease use separate formRickettsial infection Species: Ross River virus infectionRotavirus infectionRubella Non-congenital CongenitalSalmonella infection Species.

6 Severe Acute Respiratory Syndrome (SARS)Shiga toxin-producing (STEC) infection Shigellosis Species: SmallpoxSyphilis 1 2 Early latent (<2yrs) Late latent 3 CongenitalTetanusTuberculosisTularaemiaT yphoid feverVaricella-zoster virus Chickenpox Shingles UnspecifiedVibrio parahaemolyticus infectionViral haemorrhagic fever (Crimean-Congo, Ebola, Lassa, Marburg) Yersinia infection4 Tick this box if you require more forms and pre-paid envelopes (or print from ). Sept 2017 CDC-002430 SEP 17 Rural20 Notification IDADDITIONAL NOTES:Produced by Communicable disease Control Directorate Department of Health 2017