Surveillance Forms

Acute Hepatitis Non Hepatitis A-E

Adverse Events Following Immunization

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.

Creutzfeldt-Jakob Disease

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.

Enteric, Food and Waterborne

Enteric Provincial Surveillance Form with Panorama Guidance

Release of Consumer Card Information Consent Forms

Follow-up Forms

Shigellosis

Panorama Guidance Form

Panorama Guidance Form

Yersiniosis

Sexually Transmitted & Blood Borne Infections

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

Acute HBV Case Report Form

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.

HIV

HIV Case Report Form

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

HIV Partner or Contact Information Form

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.

Mpox

Surveillance Form

Complete this form for confirmed and probable mpox 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).

Tuberculosis

TB Screening Form

TB Screening Form Documentation Guide

Vaccine Preventable & Respiratory

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

Acute HBV Case Report Form

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.

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).