Office of the Chief Medical Officer of Health
REPORTABLE DISEASES AND EVENTS NOTIFICATION FORM
Please notify to the Regional Medical Officer of Health
by telephone, fax or post.
Public Health Services,
P.O. Box 5001, 300 St. Marys Street. Room 117
Fredericton, New Brunswick E3B 5H1
Phone during business hours: (506) 444-5905
Phone after hours: (506)462-0574
Fax (506) 444-4877
1. PATIENT INFORMATION
Family name:
___________________________________
Given name:
___________________________________
Street address:
___________________________________
Town, village:
___________________________________
Telephone (home):
(_______)________-__________________
Telephone (office/cell):
(_______)________-__________________
Sex:
-Male
Date of birth:
YYYY / MM / DD
-Female
Occupation and workplace or name of school/daycare attended:
___________________________________________________________
Recent travel overseas:
-No -Yes
If yes, specify country:
__________________________________
Country of birth :
__________________________________
Ethnicity:
-Aboriginal
-Black
-Other
-Caucasian
-Asian
2. DETAILS OF CONDITION
How was infection identified?
-Clinical presentation, specify onset date: YYYY / MM / DD
-Contact tracing
-Screening
Was the patient hospitalized? -No
-Yes
Laboratory confirmation of diagnosis
-Laboratory confirmed
-Linked to laboratory-confirmed case
-Laboratory confirmation pending
-No laboratory confirmation
3. REPORTING PROFESSIONAL DETAILS
5. Reportable diseases and events
Phone within one hour of identification and
write/fax by the end of the next working day
- Anthrax
- Botulism
- Cholera
- Clusters of illness, food or water-borne
- Clusters of severe or atypical illness, respiratory borne
- Diphtheria
- Hemorrhagic fever diseases
- Measles
- Plague - pneumonic
- Poliomyelitis
- Severe acute respiratory syndrome
- Smallpox
- Yellow fever
Phone within 24 hours of identification and
write/fax within seven days
- Brucellosis
- Escherichia coli (pathogenic)
- Exposure to suspected rabid animal
- Guillain-Barré syndrome
- Hantavirus pulmonary syndrome
- Haemophilus influenzae type B and non-B (invasive)
- Hepatitis A
- Legionellosis
- Listeriosis (invasive)
- Meningococcal (invasive) disease
- Mumps
- Paralytic shellfish poisoning
- Pertussis
- Plague – bubonic
- Q fever
- Rabies
- Rubella
- Staphylococcus aureus intoxications
- Streptococcus A beta-hemolytic (invasive)
- Tularemia
- Tuberculosis (active)
- Typhoid
- Unusual illness
- presence of symptoms that do not fit any recognizable clinical
picture
- known etiology but not expected to occur in New Brunswick
- known etiology that does not behave as expected
- clusters presenting with unknown etiology
- Varicella
- West Nile Virus infection
Name:
______________________________________
Telephone number:
______________________________________
Write within seven days of identification
Affiliation:
______________________________________
Signature:
______________________________________
- Adverse reaction to a vaccine or other immunizing agent
- Clostridium difficile associated diarrhea
- Creutzfeld-Jacob-Classic and New Variant
- Cytomegalovirus (congenital and neonatal)
- Hepatitis – other viral
- Herpes (congenital and neonatal)
- HIV/AIDS
- Leprosy
- Leptospirosis
- Lyme borreliosis
- Psittaccosis
- Streptococcus B beta-hemolytic (neonatal)
- Syphilis
- Tetanus
Date:
4. CLINICAL COMMENTS
YYYY / MM / DD