Australian Capital Territory Numbered Regulations

PUBLIC HEALTH (INFECTIOUS AND NOTIFIABLE DISEASES) REGULATIONS(AMENDMENT) (NO. 27 OF 1993) - REG 10

    CONFIDENTIAL     Regulations 4 and 4B

Form 1

Australian Capital Territory

Public Health Act

Public Health (Infectious and Notifiable Diseases) Regulations

This form may also be used for notifications under the Sexually Transmitted Diseases Act 1956 but the name of the patient need not be supplied.

I hereby certify that the person whose name and address appears hereunder is suspected by me to be suffering from Full name of patient Surname Given Names Address Date of Birth     Age     Sex         Male         Female Number in Household     Country of Birth Aborigine/Torres Strait Islander         Yes         No Date of onset of illness     Occupation Place of work/school

Suspected origin of disease, disposal of case, and any other remarks Action taken re contacts Diagnosis confirmed by laboratory test         Yes         No Name and Address of Medical Practitioner in BLOCK LETTERS or Stamp Signature of Medical Practitioner     To:     The Medical Officer of Health GPO Box 825 Canberra ACT 2601 Contact Phone No. (06) 2050960

    Form 2     Subregulations 4 (1)

    Australian Capital Territory     ^{and 4B (1) and (2)}

    Public Health Act

    Public Health (Infectious and Notifiable Diseases) Regulations

Attending Doctor Name	National Number (If known)
Address
	Notes for Attending Doctor Please indicate HIV infection status of the person
Hospital Name (if appropriate)		Diagnosed HIV infection (Category 1, 2 or 3) Complete Part A Only
Signature (Medical Practitioner)     /     /		Diagnosed HIV infection (Category 4 - Acquired Immune Deficiency Syndrome) Complete Parts A and B

A1 Identification of Person with HIV infection	A3 Exposure Category
	Person was interviewed with regard to exposure

Family Name (first 2 letters only)		Not at all (Detail)
Given Name (first 2 letters only)		To a certain extent (Answer questions below)
Date of Birth     /     /		In depth (Answer questions below)

Sex     Male         Female			More than one exposure category may be ticked Sexual Exposure - at least one box must be ticked
Transsexual         Postcode of current residence						Sexual contact only with person of same sex Sexual contact with both sexes (if female see A4)
A2 Diagnosis of HIV infection Date of first diagnosis of HIV infection     /     /						Sexual contact only with person of opposite sex (see A4) From a specified Country (Pattern - II or other Country 1 )     Country
State/Territory of first diagnosis of HIV infection						No sexual contact Sexual exposure not known
CD 4+ count at first diagnosis of HIV infection			Blood Exposure
Did the person present with a seroconversion illness?		Yes         No				Injecting drugs - Detail
Date of seroconversion illness		/     /				Recipient of blood, blood products or tissue - Detail
						Haemophilia/coagulation disorder - Detail
Has the person had a previous negative antibody test?		Yes         No	Vertical Transmission
Date of last negative antibody test		/     /				Mother with/at risk of HIV infection - (see A5)
Source of last negative test		Patient	Other Exposure
		Doctor				Exposure other than those above applies - Detail
		Laboratory				Exposure could not be established - Detail
A4 Sexual contact with person of opposite sex				A5 Vertical Transmission
Please indicate category of source person				Mother with/at risk of HIV infection due to
					Injecting drug use
	Bisexual male (women only)				Recipient of blood, blood products or tissue
	Injecting drug user				Origin in Pattern - II or other Country 1
	Person who received blood, blood products or tissue				Country
	Person with haemophilia/coagulation disorder				Has HIV infection, exposure not specified
	Person from Pattern - II or other Country 1				Sex with bisexual male
	Country				Sex with injecting drug user
	Person with HIV whose exposure is other than those above     Specify				Sex with person who received blood, blood products or tissue Sex with person with haemophilia/coagulation disorder
	Person with HIV, exposure not specified				Sex with person from Pattern - II or other Country 1     Country
	Other exposure				Sex with person with HIV, exposure not specified
	Detail				Other exposure     Detail

B1 Diagnosis of HIV infection (Category 4 - Acquired Immune Deficiency Syndrome)		B5 Diseases indicative of Category 4 Diagnosis     At lease one must be ticked Definitive Presumptive
Date of Category 4 diagnosis     /     /				Pneumocystis carinii pneumonia
Has the person been previously diagnosed as Category 4 elsewhere?         Yes         No/Unknown				Oesophageal candidiasis
(1)     If YES and diagnosis was in another State/Territory     Specify				Kaposi's sarcoma     Site Herpes simplex virus > 1 month duration     Site
(2)     If YES and diagnosis was overseas, write country				Cryptococcosis     Site
				Cryptosporidiosis (diarrhoea > 1 month)
B2 Other characteristics of Category 4				Toxoplasmosis     Site
Country of Birth         Australia				Cytomegalovirus     Site
Other specify				Mycobacteriosis     Type
If other, state year of arrival in Australia				Lymphoma     Site     Type
Current Status of Person				HIV encephalopathy
(1)     Person is alive. Date of most recent contact     /     / (2)     Person has died. Date of death     /     /				HIV wasting syndrome
					Invasive cervical cancer

			Tuberculosis     Site
			Multiple episodes of bacterial pneumonia
B3 Laboratory Tests for Category 4 Diagnosis	Other specify

Date of first diagnosis of HIV infection     /     /
CD4 + count at Category 4 Diagnosis CD4 + results to be forwarded when available
Date of specimen collection for CD4 + count analysis     /     /	Footnote 1	Pattern - II countries
B4 Antiretroviral Therapy	The original Pattern - II countries were sub-Saharan Africa and the Caribbean, where transmission is thought to be predominantly heterosexual. This definition should now be expanded to include countries from South East Asia and India.
Indicate if the person has been treated with any of the following antiretroviral agents (If YES, Specify month/year when started)	ACT Health - Office Use Only
19     Zidovudine     19     ddl	Initials of ACT Health Officer
19     ddC     19     Other	Territory Case No.
	Date notification received at Health		Date forwarded to National Centre
Specify	/     /		/     /
			h2560(8/92)

    Form 4     Subregulation 14A (1)

Australian Capital Territory

Public Health Act

Public Health (Infectious and Notifiable Diseases) Regulations

					(VACCS) Record No.
Name:         DOB:
Address:         Sex:
To be completed by authorised person
Recommended age	Immunisation	Batch No.	Date Given	Signature and Stamp		Next Dose Due