Required fields are marked with asterisks (*)

COVID-19 (SARS-CoV-2) Fatalities Reporting Form

Please complete all applicable areas and return this form for the Medical Officer of Health for Ottawa Public Health as soon as possible, within 12 hours when feasible.

Telephone: 613-580-2424, ext. 24224; Fax:613-580-9640
COVID-19 Case and Contact Team, 100 Constellation Drive, 8 East, Ottawa ON K2G 6J8

Patient Information

Ontario health card #:

Last name:

First name:

Date of birth (YYYY-MM-DD):

Sex:

Address:

City:

Postal code:

Primary telephone #:

Alternative telephone #:

COVID-19 (SARS-CoV-2) Details

COVID-19 (SARS-CoV-2) laboratory confirmed? (Do not report cases confirmed by Rapid Antigen Test only)

Yes

Specimen type:

Molecular (i.e., PCR, NAAT)

Serology

Other

Upload specimen results, if available

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Allowed extensions pdf

Specimen ID:

Specimen collection date (YYYY-MM-DD):

Specimen positive result date (YYYY-MM-DD):

Symptom onset date (YYYY-MM-DD):

Date of death (YYYY-MM-DD):

Which of the following death attributions related to COVID-19 applies to the patient?

COVID-19 was the underlying cause of death

COVID-19 contributed to but was not the underlying cause of death

COVID-19 was unrelated to the cause of death

Cause of death was unknown

Medical Certificate of Death completed:

Yes

Medical Certificate of Death faxed to OPH:

Yes

Reporting Physician Information

Name:

Specialty / Name of Reporting Agency:

Phone Number:

Alternate Phone Number:

Signature of Reporting Physician

Clear

Attestation:

I certify that the information provided above is true to my knowledge.

If COVID was the underlying cause of death, COVID-19 should be provided in Part I of the Cause of Death section of the Medical Certificate of Death, i.e., as the Immediate or Antecedent cause of death. For additional details and examples, please see the Technical Note from the World Health Organization. When there was a clear alternative cause of death, e.g, trauma, drug toxicity, other natural death process, at a time that the person was COVID-19 test positive but did not have a clinically compatible illness, COVID-19 should not be provided as the Immediate or Antecedent cause of death.

Personal information on this form is collected under the authority of the Health Protection and Promotion Act, Sections 22 and 24, and will be used for public health follow-up. Any questions should be directed to the COVID-19 Case and Contact Management Team at 613-580-2424, ext. 24224. Please provide your designation and reason for calling when leaving a voicemail to ensure call priority.

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COVID-19 (SARS-CoV-2) Fatalities Reporting Form

Patient Information

COVID-19 (SARS-CoV-2) Details

Reporting Physician Information

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