Provincial Case ID
- -
Client ID
Disease name
Hepatitis B, C, and D Case Report Form
Disease name
If Hepatitis B, please specify:
Acute
Provincial Case ID
-
(ANDS ID)
Chronic (or Chronic Carrier)
-
Client ID
(Note: see ANDS quick reference guide for reporting standards)
(DHA generated)
TESTING HISTORY (complete when applicable)
Previously tested positive for
Hepatitis:
Yes
No
/
Date of first positive test
(yyyy)
Where tested positive
(province/country):
/
(mm)
(dd)
CLINICAL INFORMATION
Symptoms
Y
N
U
Date of onset
yyyy
mm
dd
Abdominal Cramps
/
/
Fatigue
/
/
Fever
/
/
Jaundice
/
/
Loss of Appetite
/
/
Nausea/Vomiting
/
/
Other
/
/
Hepatitis B, C, D Case Report Form 2015 v2.0
Provide Details
Page 1 of 7
Provincial Case ID
- -
Client ID
Disease name
POTENTIAL EXPOSURE / RISK FACTORS
Medical Risks
Y
N
U
Where
(if applicable:
city/province/country)
yyyy
Dental care or oral surgery
Date
mm
/
/
/
/
/
/
/
/
Renal dialysis
/
/
Received Immune Globulin
/
/
Hemophiliac or requiring coagulation products
/
/
Received Donation: (select all that apply)
Tissue
Organ
Blood
Blood Products
Semen
Other:
/
/
Provided Donation: (select all that apply)
Tissue
Organ
Blood
Blood Products
Semen
Other:
/
/
If yes, was the dental care or oral surgery performed outside of the country?
Diagnostic/surgical procedure
If yes, was the diagnostic/surgical procedure performed outside the country?
Personal Risks
Y
Has the patient ever injected drugs not prescribed by a doctor
(including steroid injection)?
If yes, share needles, syringes or other materials (e.g. cooker, cotton)?
Non-injection drug use
If yes, share straws or other equipment (e.g. crack pipes)?
Acupuncture
N
U
Where
(if applicable:
city/province/country)
yyyy
Date
mm
/
/
/
/
/
/
/
/
/
/
/
/
Provide Details
dd
(i.e. Name and details of relevant facility)
dd
(i.e. Name and details of relevant facility)
Provide Details
Use of personal services where the skin may intentionally or
unintentionally be broken: (select all that apply)
Facial/microdermabrasion
Ear/body piercing
Manicure/pedicure
Injection of fillers
Other:
Hepatitis B, C, D Case Report Form 2015 v2.0
Page 2 of 7
Provincial Case ID
- -
Client ID
Disease name
Personal Risks
Y
N
U
Where
(if applicable:
city/province/country)
yyyy
Tattoo/micro-pigmentation (e.g. semi-permanent make up)
If yes, where was the procedure performed? (select all that apply)
Date
mm
dd
/
/
/
/
Electrolysis (ask if disposable needles)
/
/
Percutaneous exposure (e.g. needle stick injury)
/
/
History of travel/residence in an endemic country (Hepatitis B cases only)
/
/
History of time in jail/prison (enter most recent date of incarceration)
/
/
Is a household/family member known to be positive?
/
/
Other exposure?
/
/
Commercial parlor/shop
Other:
Correctional facility
Body modification: (select all that apply)
Scarification
Branding
Implanting
Other:
Sexual Risks
Since becoming sexually active, have you engaged in any of the following?
Y
N
U
Where
(if applicable:
city/province/country)
Date
yyyy
Provide Details
mm
Unprotected sex with someone of the opposite sex?
/
/
Unprotect sex with someone of the same sex?
/
/
Unprotected sex with someone who is hepatitis B, hepatitis C or
hepatitis D positive?
/
/
Unprotected sex with someone who engages in high risk activity, such as
an illicit drug user or sex trade worker?
/
/
Occupational exposure
Y
N
U
Where
(if applicable:
city/province/country)
(i.e. Name and details of relevant facility)
dd
(i.e. Name and details of relevant facility)
Provide Details
mm
Direct contact with blood while employed in a medical or dental field?
/
/
Direct contact with blood while employed/volunteered as a public safety
worker (e.g. correctional officer, police, fire/rescue)?
/
/
Other occupational exposure (specify)
/
/
Hepatitis B, C, D Case Report Form 2015 v2.0
dd
Date
yyyy
Provide Details
(i.e. Name and details of relevant facility)
Page 3 of 7
Provincial Case ID
- -
Client ID
Disease name
HEPATITIS CLIENT EDUCATION CHECKLIST
Discussed with client the importance of the following: (select all that apply)
Health Protection
Not sharing IV drug equipment
Not sharing any drug inhalation equipment
Disclosure of Hepatitis status to health care professionals who may be involved in care
Disclosure of Hepatitis status to any current or future sexual partners & safer sex practices
Disclosure of Hepatitis status to any current or future IVD or inhalation drug contacts
Not donating any blood or body tissues
Not sharing personal items such as razors and nail clippers
Proper cleaning of any blood spills: wear disposable gloves; clean up spill using paper towels; wipe spot with 1 part bleach (100mls) to 9 parts water (900mls); allow
solution to stay in for 10 mins before wiping off; dispose of paper towel in garbage; remove and dispose of gloves and wash hands.
Healthy Living
Importance of healthy lifestyle, including limited use of alcohol
Importance of checking with physician or pharmacists before using medications, including vitamins and over the counter meds
How to access clean needle program or addiction services if appropriate
Offered immunizations if applicable – Hepatitis A and B; pneumococcal; tetanus booster; influenza
Hepatitis B, C, D Case Report Form 2015 v2.0
Page 4 of 7
Provincial Case ID
- -
Client ID
Disease name
IMMUNIZATION HISTORY (if applicable)
Has the patient previously received the Hepatitis A vaccine?
If yes, how many doses?
If yes, when was the last dose received?
Yes
No
Unknown
1
2
3
(yyyy)
Has the patient previously received the Hepatitis B vaccine?
If yes, how many doses?
If yes, when was the last dose received?
If yes, how many doses?
If yes, when was the last dose received?
(mm)
/
(dd)
Yes
No
Unknown
1
2
3
(yyyy)
Has the patient previously received Combination Hepatitis A & B (Twinrix)?
/
>3
/
(mm)
/
(dd)
Yes
No
1
2
(yyyy)
/
(mm)
/
>3
(dd)
IMMUNIZATION OF CASE
Hepatitis A:
Yes
No
Dose #1
Unknown
(yyyy)
/
(mm)
/
(dd)
Dose #2
(yyyy)
/
/
/
/
/
/
(mm)
(dd)
Additional Doses:
Hepatitis B:
Yes
No
Dose #1
Unknown
(yyyy)
/
(mm)
/
(dd)
Dose #2
(yyyy)
(mm)
(dd)
Dose #3
(yyyy)
/
/
/
/
(mm)
(dd)
Additional Doses:
Combination Hepatitis A & B (Twinrix):
Yes
No
Dose #1
Unknown
(yyyy)
/
(mm)
/
(dd)
Dose #2
(yyyy)
(mm)
(dd)
Dose #3
(yyyy)
(mm)
(dd)
Additional Doses:
Other vaccines (as applicable):
Pneumococcal 23:
(yyyy)
/
(mm)
Hepatitis B, C, D Case Report Form 2015 v2.0
/
(dd)
Tdap:
(yyyy)
/
(mm)
/
(dd)
Annual Influenza:
(yyyy)
/
(mm)
Page 5 of 7
/
(dd)
Provincial Case ID
- -
Client ID
Disease name
FOLLOW-UP OF CONTACTS
Household Contacts
Last Name
First Name
Relationship
Is PH follow-up
Indicated?
Y
N
Serology
Results
Serology Date
yyyy
mm
/
/
/
HBIG Date if
indicated
dd
yyyy
/
mm
/
/
/
/
/
dd
/
/
/
Vaccine Dates or
attached recips
yyyy
mm
dd
1.
/
/
2.
/
/
3.
/
/
1.
/
/
2.
/
/
3.
/
/
1.
/
/
2.
/
/
3.
/
/
Comments (e.g. contacts lost to follow, education provided):
Sexual/Other Contacts (share drugs etc.)
Last Name
First Name
Address
Phone
Informed
(by whom)
Serology Date if
indicated
yyyy
mm
/
/
/
dd
/
/
/
HBIG Date if
indicated
yyyy
mm
/
/
/
dd
/
/
/
Vaccine Dates or
attached recips
yyyy
mm
/
/
2.
/
/
3.
/
/
1.
/
/
2.
/
/
3.
/
/
1.
/
/
2.
/
/
3.
/
/
Comments (e.g. contacts lost to follow, education provided):
Hepatitis B, C, D Case Report Form 2015 v2.0
dd
1.
Page 6 of 7
Provincial Case ID
- -
Client ID
Disease name
MOST LIKELY PRIMARY EXPOSURE IDENTIFIED
Yes
No
If yes, please indicate:
Medical Officer of Health
Requires CBS referral
Yes
No
If yes, please provide details:
MoH Comments:
CASE MANAGEMENT LOG
Attempt
Date
yyyy
Time
mm
dd
1
/
/
2
/
/
3
/
/
4
/
/
5
/
/
hh:mm
Comments
Public Health Staff/Reporter
Comments:
Collection Date
Reporter’s Name/Signature:
Hepatitis B, C, D Case Report Form 2015 v2.0
yyyy
/
mm
/
dd
Page 7 of 7