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Reportable Infectious Diseases and Events Reporting Form

Name of reporting agency:

Telephone number:

Ext.

Name of person reporting:

Patient Information

Ontario health card number:

Last name

First name

Gender:

Date of birth:

Age:

Address:

City:

Postal code:

Home telephone number:

Alternative telephone number:

Occupation:

Name of school/child care centre:

Disease Information

Disease:

Specimen type:

Onset date:

Specimen collection date:

STI lab specimen number:

Upload lab results or other supporting documents, if available

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Allowed extensions pdf, jpg, jpeg, gif, png, tif

Treatment History

Is STI treatment information available at reporting time?

Yes

Treatment:

Treatment date:

Hospitalized?

Yes

Physician Information

Name:

Specialty:

Address:

City:

Postal code:

Telephone number:

Attestation

By completing this form, I certify that the above information is accurate and that my signature is valid.

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 Infectious Disease Program at 613-580-2424, ext. 24224.

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Reportable Infectious Diseases and Events Reporting Form

Patient Information

Disease Information

Treatment History

Physician Information

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