Diseases of Public Health Significance Notification Form

Patient information

Last name

First name

Date of birth

Date reported

Gender

Male

Female

Transgender

Unknown

Pregnant

Yes

No

Not applicable

Street address

City

Postal code

Home phone number

Cell phone number

Reporting information

Physician

Physician phone number

Physician fax number

Family physician (if different from above)

Family physician phone number

Family physician fax number

Is the patient hospitalized?

Yes

No

Emergency room visit

Yes

No

Transported by ambulance

Yes

No

Recent travel history

Yes

No

Contact of a known or suspect case

Yes

No

Clinical presentation

Symptom

Onset date

Add symptom Remove symptom

Testing

Diagnostic ordered

Collection date

Add diagnostic Remove diagnostic

Treatment

Medication ordered

Start date

Add treatment Remove treatment

Personal health information is collected under the authority of the Health Protection and Promotion Act R.S.O. 1990 c.H.7, s. 5 (as amended) and in accordance with the Personal Health Information Protection Act, 2004, S.O. 2004, c.3. This information is collected and used for the purpose of processing your submitted notification form of a disease of public health significance and to conduct necessary follow-up with the reporting health care provider and affected individual; for preventing, eliminating and/or decreasing the effects of a health hazard; and, to inform Health Department program delivery, evaluation, and administration. The information collected in this form is used to create an electronic health record for the affected individual and is maintained electronically in a shared provincial information system. Questions about this collection of information should be addressed to Durham Region Health Department, Manager, Health Information, Privacy and Security at 605 Rossland Rd E, PO Box 730, Whitby, ON L1N 0B2 905-668-7711.