Alberta Health
Public Health Notification of
West Nile Virus to Canadian Blood Services
SECTION 1: DONOR/RECIPIENT INFORMATION
Last Name:
First Name:
Birth Date (yyyy-mm-dd):
Address:
City:
Province/Territory: AB
Onset Date:
Suspect West Nile Neurological Syndrome (WNNS)
Classification:
Probable/Confirmed West Nile Non-Neurological
Syndrome (WN Non-NS)
Test Result
Negative
Probable/Confirmed WNNS
Confirmed West Nile Asymptomatic Infection
Date of Test:
Positive (Please attach copy of WNv laboratory result)
SECTION 2: DONATION HISTORY
History of blood DONATION in the 56 days (8 weeks)
prior to onset of symptoms?
Yes
CBS Donor Number (if available):
1. City of Donation:
Name at Time of Donation:
2. City of Donation:
Name at Time of Donation:
No
SECTION 3: RECIPIENT HISTORY
History of blood/blood component TRANSFUSION in the 56 days (8 weeks) prior to onset of
symptoms?
Yes
No
If Yes, please provide dates and location:
1. Hospital:
Town/City
Transfusion Date:
Name at time of transfusion:
2. Hospital:
Town/City
Transfusion Date:
Name at time of transfusion:
3. Hospital:
Town/City
Transfusion Date:
Name at time of transfusion:
SECTION 4: ADMINISTRATIVE INFORMATION
Date Reported to CBS:
Reported by:
Zone/Region reporting: Zone - Region
Telephone number:
-
ext
COMMENTS:
Forward completed information to the CBS by phone and fax:
Calgary
Edmonton
(24 hrs)
Mon – Fri, 2100 – 0800 hrs
Sat & Sun after 1600 hrs
Mon – Fri, 0800 – 2100 hrs
Phone: 780-431-0777
Phone: 403-410-2737
Phone: 403-589-3399
Fax:
Fax:
Fax:
780-433-4478
Surveillance and Assessment
Updated August 27, 2012
403-410-2791
403-410-2791