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Notification form
Notification ID
4
(tick box below)
Measles
Melioidosis
/
/
Date of death
/
/
Date of onset
Meningococcal infection Meningitis Septicaemia Other
dd
mm
yyyy
(if applicable)
dd
mm
yyyy
Mumps
Place infection acquired WA Interstate Overseas Unknown
Paratyphoid fever
Pertussis
If acquired interstate/overseas, specify
Plague
Pneumococcal infection (invasive)
Was the patient hospitalised? No
Yes
Poliomyelitis
How was diagnosis made?
Psittacosis (ornithosis)
Q fever
Lab Result pending Linked to lab-confirmed case Clinical only
Rheumatic fever (acute) use separate form
Result:
Method:
Rickettsial infection (typhus) Species:
Ross River virus infection
FOLLOW-UP (tick one or more)
Rotavirus infection
Rubella
Non-congenital Congenital
Patient/carer aware of diagnosis and that it is a notifiable disease.
Salmonella infection
Risk to contacts discussed with patient.
Schistosomiasis
Shiga toxin/verotoxin producing E.coli (STEC/VTEC) infection
Patient/carer aware Public Health Unit may contact them for information.
Shigellosis Species:
Other
Smallpox
CLINICAL COMMENTS (risk factors, presentation, treatment)
Syphilis 1o 2o Early latent (<2yrs) Late latent 3o Congenital
Tetanus
Tuberculosis
Tularaemia
Typhoid fever
Varicella-zoster virus
Chickenpox Shingles Unspecified
Vibrio parahaemolyticus infection
Viral haemorrhagic fevers (Crimean-Congo, Ebola, Lassa, Marburg)
NOTIFIER DETAILS
Yellow fever
Yersinia infection
Name ................................................................................... Phone ....................................................
Clinic/Hospital .................................................................................................................................... Has your patient been vaccinated for this disease?
Yes No
If yes and not recorded on ACIR (e.g. adult), specify below Unknown
Address ..................................................................................................................................................
Vaccine (Specify generic
Date
Validation
administered
or proprietary name)
.......................................................................................................... Postcode ....................................
Medical or health record
1.
/ /
Self-recall
Signature ....................................................................................... Date ........../........../.................... 2.
dd
mm
yyyy
Tick this box if you require more forms and pre-paid envelopes (or print from www.public.health.wa.gov.au/3/522/3/forms.pm).
August 2014
2 0
Notification ID
CDC-002430 AUG14
ADDITIONAL NOTES: