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Surveillance Forms

 

 Vaccine Preventable / Respiratory

This form should be used by public health nurses for enhanced surveillance of acute hepatitis B as part of the BC Hepatitis Enhanced Surveillance Project (BCHESP)..
All influenza-like illness (ILI) outbreaks occurring in schools, work sites, acute care facilities, residential institutions (e.g. long-term care facilities, seniors' residences), and other facilities of interest (e.g. correctional facilities) should be reported to BCCDC by the responsible health unit or authority. This form can be delivered by fax (604-707-2516) or email. ILI outbreaks are defined as follows:

  • Schools and work sites: greater than 10% absenteeism on any day, most likely due to ILI
  • All other facilities: two or more cases of ILI within a seven-day period
Facilities experiencing outbreaks should submit specimens using the "6-packs". Before shipping the specimens, the “ILI Outbreak Laboratory Form” should be FAXED, with all patients' names clearly written, to the PHSA Laboratory Services at 604-707-2675. The Influenza Like Illness (ILI) Outbreak Laboratory Form should also be included with the specimens when they are shipped.
All Group A Streptococcus cases should first be reported by phone to the on-call person in Epidemiology at 604-707-2510. Following reporting, you may download this form, complete and return it by fax to Epidemiology Services, BCCDC at 604-707-2516.
In order to monitor and evaluate the dose schedule change of the conjugate pneumococcal vaccine in British Columbia, the Health Authorities are requested to complete this enhanced surveillance form for all confirmed cases of IPD AGED 0-16 YEARS and fax it to Epidemiology Services, BCCDC at 604-707-2516.
All measles cases should first be reported by phone to the on-call person in Epidemiology Services at 604-707-2510. Please use this form to report enhanced surveillance data for all cases of measles, mumps and rubella and return it by fax to Epidemiology Services, BCCDC at 604-707-2516.
All Meningococcal cases should first be reported by phone to the on-call person in Epidemiology Services at 604-707-2510. Following reporting, you may download this form, complete and return it by fax to Epidemiology Services, BCCDC at 604-707-2516.
Pertussis
For all Severe Acute Respiratory Syndrome (SARS) reported, please complete this surveillance form and fax it to Epidemiology Services, BCCDC at 604-707-2516.
 

Enteric, Food & Waterborne

 

Vectorborne, Zoonotic and Environmental

In June 2003, all cases of Cryptococcus became provincially reportable. All culture confirmed cases regardless of subtype (C. gattii, C. grubii, C. neoformans) should be reported through iPHIS. Cases may also be diagnosed by serology or histopathology; please consult the decision tree at the end of the attached questionnaire to determine if a case requires follow-up in addition to iPHIS reporting. If yes, please download and complete the questionnaire and return it by fax to Epidemiology Services, BCCDC at 604-707-2516.
 
For all Lyme disease cases, please download and complete this questionnaire, and return it by fax to Epidemiology Services, BCCDC at 604-707-2516. For a description of late complications and a picture of Erythema migrans (EM), please refer to the Lyme Disease glossary of terms.
In case of rabies, immediately contact the on-call person in Epidemiology Services at 604-707-2510. To request the release of biologicals use the Rabies Exposure Report and Rabies Biologicals Request Form. For the recording of Immune Globulin Administration, use the Rabies Immune Globulin Administration Record form. You should also refer to the Communicable Disease Control Manual for further explanations on the use of these forms.
This form for health authority staff must accompany each bird specimen submitted for WNV testing by the Animal Health Centre, Abbotsford. When completed, each form should be enclosed in its own waterproof bag and attached to the corresponding bird carcass.
This form is to be used in reporting investigations of human cases relating to West Nile Virus. Please fax all completed questionaires to the Epidemiology Services, BCCDC at 604-707-2516.  Attention: Marsha Taylor
This form for health authority staff must accompany each mosquito trap content submitted for WNV testing by the BCCDC. When completed, each form should be accompanied with mosquito trap content.
  

Cocaine-Associated Agranulocytosis

This form is to be completed by the local Medical Health Officer. Please FAX to BCCDC at 604-707-2516.
  

Sexually Transmitted Infections (STI)

AIDS is a reportable disease in British Columbia. AIDS reporting is accomplished by submitting a BC AIDS Case Report Form to the BC Centre for Disease Control, Division of STI/HIV Prevention and Control. If an AIDS-defining illness is diagnosed in an HIV positive patient, please download this form, complete and return by mail to:

The BC Centre for Disease Control Division of STI/HIV Prevention and Control
HIV/AIDS Surveillance Nurse
655 West 12th Avenue, Vancouver, B.C. V5Z 4R4
 

Tuberculosis (TB)
 

Creutzfeldt-Jakob Disease (CJD)

Confirmed Creutzfeldt-Jakob Disease (CJD) became reportable in BC in March 2007. To facilitate reporting when a case of CJD is confirmed by the National CJD surveillance system (CJD-SS) they will enter case details into the form and send to the attending neurologist. The neurologist will complete additional details and fax to public health to notify medical Health Officer. Please enter the case details into iPHIS and fax the form to Epidemiology Services, BCCDC at 604-707-2516.

Adverse Events Following Immunization

 
Adverse Events Following Immunization, or AEFI (formerly called Adverse Vaccine Reaction or Vaccine Associated Adverse Event) are reportable under a voluntary scheme in British Columbia to monitor vaccine safety. This form HLTH 2319 is published by the Ministry of Health to facilitate reporting by health care providers to their local health unit. After filling and printing the form, submit it to your local health unit office, or send/fax to the central office in your jurisdiction. Data from the form are to be entered into iPHIS or PARIS by public health staff. Criteria for reporting and management of adverse events are found in Section 9 of the Immunization Program Manual. Guidelines for public health staff for entering AEFI data into iPHIS are located on PartnerNet (password required) under 3.0 Immunization Policies under item 3.10 Guidelines fo the reporting of vaccine adverse events.
Please use this form for every case of anaphylaxis following H1N1 vaccine (requiring emergency intervention) reported by Public Health.
Please use the Anaphylaxis Report Form when two or more cases of anaphylaxis occur in association with the same lot of vaccine(s) within a week in a health unit, or when requested to do so by BCCDC.


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Last Updated: December 11, 2009
 

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