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Surveillance Forms

 
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Report of Adverse Event (Reaction) Following Immunization


Instructions for Clinicians and Pharmacists:

Health care providers including physicians and pharmacists are required by law to report Adverse Events Following Immunization (AEFI) to monitor vaccine safety. Please complete the AEFI Report Form and send it to the local health unit (see Where to submit an AEFI report).


AEFI report form - short version


Instructions for Public Health:

Data from the form are to be entered into Panorama or PARIS by public health staff. Additional information collection may be required for public health reporting (contained in the AEFI report form long version below) is available. Criteria for reporting and management of adverse events are found in the BC Communicable Disease Control Manual, Chapter 2: Immunization, Part 5.


AEFI report form - long version (for use by public health)


Part 5 - Adverse Events Following Immunization


AEFI Data Entry Guidelines 

The following resource is intended for BC health care providers completing the AEFI case report form or the Panorama AEFI form: User Guide for Completion and Submission of Adverse Events Following Immunization (AEFI) Reports.


Worksheet for Events Managed as Anaphylaxis Following Immunization

Anaphylaxis Worksheet

Events managed as anaphylaxis following immunization may be recorded on this BCCDC worksheet. This worksheet should be completed by the immunizing health care professional that observed and treated the client who experienced the anaphylactic episode. Management guidelines for these events are found in the BC Communicable Disease Control Manual, Chapter 2: Immunization.


Part 3 - Management of Anaphylaxis in a Non-Hospital Setting


After filling and printing the form, please submit the form to the appropriate Medical Health Officer (MHO) for review. Please also complete a Panorama report on this adverse event.

 

 BC Case Report Form

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

 

Reporting Form 

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 Communicable Diseases and Immunization Service, BCCDC at 604-707-2516.

             

             
             

             

            AIDS

            Case Report Form

            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


            Gonorrhea and Chlamydia

            • HLTH208 - Confidential Notification of Sexually Transmitted Infection Case Report Form (see below)

            Gonorrhea and chlamydia are reportable diseases in British Columbia.


            If gonorrhea and/or chlamydia are diagnosed within Vancouver Coastal Health Authority, or Fraser Health Authority, please download the following form (H208 – BCCDC), complete and return to: 

            The BC Centre for Disease Control 
            Division of STI/HIV Prevention and Control 
            655 West 12th Avenue
            Vancouver, B.C. V5Z 4R4
            Fax: 604 707 5604

            If gonorrhea and/or chlamydia are diagnosed within Vancouver Island Health Authority, Northern Health Authority or Interior Health Authority, please download the following form 
            (H208 – VIHA_NHA_IHA), complete and return to the Public Health or Communicable Disease Unit assigned to follow up in these areas. Please note that the return mailing address and fax are left blank to accommodate the corresponding health authority.     


            Hepatitis B: Acute HBV

            As of January 1st, 2016, this form should be used by public health nurses for follow-up and surveillance of individuals identified with acute hepatitis B, in accordance with the follow-up practices of each Health Authority.      


            Hepatitis C: Acute HCV

            As of January 1, 2016, this form should be used by public health nurses for follow-up and surveillance of individuals identified with acute hepatitis C, in accordance with the follow-up practices of each Health Authority.


            HIV

            HIV is a reportable disease in British Columbia. This surveillance form is intended for use by public health nurses responsible for the follow up, support and management of newly diagnosed HIV positive individuals in their Health Authority. Please download, complete and submit the form to:


            HIV Surveillance Services

            The BC Centre for Disease Control 

            Clinical Prevention Services

            Provincial STI/HIV Clinic

            655 West 12th Avenue

            Vancouver, B.C. V5Z 4R4

            Fax: 604 707 5604


            This form can be used by public health nurses as an adjunct to the HIV Case Report Form. It is intended to be used as a support tool or template to guide Partner or Contact notification and services for individuals who have been identified by an index case as being at risk of exposure to HIV during the trace-back period. This form is not to be submitted to BCCDC.


             

             
             

             

            COVID-19

            Enterovirus D68

            All lab-confirmed cases of enterovirus D68 (EV-D68) should be entered in an electronic data management system for communicable diseases (Panorama/PARIS). For EV-D68 cases associated with respiratory (non-neurologic) clinical presentation, please use the general ‘Enterovirus D68 Case Report Form’. For EV-D68 cases associated with neurologic illness, please use the ‘Neurologic Illness Associated with Enterovirus D68 Case Report Form’.  Case definitions can be found in the linked forms.


            Hepatitis B: Acute HBV

            As of January 1st, 2016, this form should be used by public health nurses for follow-up and surveillance of individuals identified with acute hepatitis B, in accordance with the follow-up practices of each Health Authority.


            Influenza

            Influenza Severe Outcome Surveillance (SOS) Case Report Form

            Severe cases of influenza can be reported in an electronic data management system for communicable diseases (Panorama/PARIS) at the discretion of regional Health Authorities. Refer to Case Report Form for influenza severe outcome surveillance (SOS) case definitions.


            Avian Influenza

            Avian Influenza Case Report Form


            This form should be used by public health for follow-up and surveillance of individuals identified with avian influenza, in accordance with the follow-up practices of each Health Authority.


            Influenza-like Illness

            ILI Outbreak Report Form

            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

            Invasive Group A Streptococcus

            Case Report Form

            Complete this form for every case of invasive group A Streptococcal disease. Submit completed forms to Immunization Programs and Vaccine Preventable Diseases Service, BCCDC by fax (604-707-2515) or e-mail (vpd.epi@bccdc.ca). 

            All cases should also be reported in an electronic data management system for communicable diseases (Panorama/PARIS). 


            Invasive Haemophilus influenzae type b

            Case Report Form

            Complete this form for every case of invasive Haemophilus influenzae type b disease. If required, submit completed forms to

            Immunization Programs and Vaccine Preventable Diseases Service, BCCDC by fax (604-707-2515) or e-mail (vpd.epi@bccdc.ca). 


            All cases should also be reported in an electronic data management system for communicable diseases (Panorama/PARIS). 


            Invasive Pneumococcal Disease

            Case Report Form

            Complete this form for every case of invasive pneumococcal disease AGED 0-16 YEARS. Submit completed forms to Immunization Programs and Vaccine Preventable Diseases Service, BCCDC by fax (604-707-2515) or e-mail (vpd.epi@bccdc.ca). 

            All cases should also be reported in an electronic data management system for communicable diseases (Panorama/PARIS). 


            Measles, Mumps & Rubella 

            Measles Case Report Form
            Mumps Case Report Form
            Rubella Case Report Form


            Congenital Rubella 

            Case Report Form

            Complete a form for every case of measles, mumps or rubella disease. Submit completed forms to Immunization Programs and Vaccine Preventable Diseases Service, BCCDC by fax (604-707-2515) or e-mail (vpd.epi@bccdc.ca).


            All cases should also be reported in an electronic data management system for communicable diseases (Panorama/PARIS).


            Invasive Meningococcal Disease

            Case Report Form

            Complete this form for every case of invasive meningococcal disease. Submit completed forms to Immunization Programs and Vaccine Preventable Diseases Service, BCCDC by fax (604-707-2515) or e-mail (vpd.epi@bccdc.ca). 

            All cases should also be reported in an electronic data management system for communicable diseases (Panorama/PARIS). 

            Pertussis

            Minimum data elements for provincial reporting for all probable and confirmed cases of pertussis should be reported in an electronic data management system for communiable diseases (Panorama/PARIS). For VCH only, completed forms should be faxed to Immunization Programs and Vaccine Preventable Diseases Service, BCCDC, at 604-707-2516.


            Case Report Form


            Contact Management and Treatment forms are provided for use within Health Authorities. These forms do not need to be submitted to BCCDC.


            Contact Management Form
            Pertussis Forms
            Treatment Form 


            Other Vaccine Preventable Diseases

            Case Report Form


            Complete a form for every case of poliomyelitis, tetanus, and for every case and carrier of toxigenic diphtheria.  


            Enter reportable cases into Panorama or PARIS.  If required, submit completed forms to Immunization Programs and Vaccine Preventable Diseases Service, BCCDC by fax (604-707-2515) or e-mail (vpd.epi@bccdc.ca).



            Legionella

            Lyme Disease

            Monkeypox 

            Complete this form for confirmed and probable monkeypox cases and submit electronically (preferred) or by fax to CDIS 604-707-2516. Cases should also be entered in an electronic data management system for communicable diseases (Panorama/PARIS).

            Rabies

            In case of rabies, immediately contact the on-call person in Communicable Diseases and Immunization Service at 604-707-2510. Refer to the Rabies section in the Communicable Disease Control Manual for management of suspected rabies exposures. 


            West Nile Virus

            This form is to be used in reporting investigations of human cases relating to West Nile Virus. Please fax all completed questionnaires to the Communicable Diseases and Immunization Service, BCCDC at 604-707-2516. Attention: Marsha Taylor

            Zika Virus

             
            SOURCE: Surveillance Forms ( )
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