Government of South Australia
SA Health

Report of Notifiable Condition or Related Death

South Australia Public Health Act 2011

URGENT NOTIFICATION - Phone 1300 232 272 the Communicable Disease Control Branch(CDCB) 24 hours/7 days

PHONE/FAX notification for all diseases listed on this form (except mycobacterial disease) to CDCB as soon as practicable and, in any event, within 3 days of suspecting or confirming a diagnosis of a notifiable disease. Telephone 1300 232 272. or fax (08) 8226 7187

To notify sexually transmitted infections or blood borne viruses use specific STI or BBV form. DO NOT USE THIS FORM See www.sahealth.sa.gov.au/NotifiableDiseaseReporting

To notify mycobacterial disease telephone SA Tuberculosis Services on (08) 7117 2983 within 3 days of suspicion or confirmation of diagnosis. OR USE THIS FORM and send via fax to (08) 7117 2998

 
A CASE DETAILS (Please print clearly and tick all applicable box)
Title
Last Name
Given Name
Address
Suburb Postcode
Contact Number
Date of Birth(dd/mm/yyyy)      Sex
Date of Death(dd/mm/yyyy) (if applicable)
Is the person of Aboriginal or Torres Strait Islander origin?
Occupation
Person Hospitalised due to the notifiable Disease?
Is the person/caregiver aware of the diagnosis?
B DISEASE TO NOTIFY (Please select at leat one disease from the check boxes)
Date of onset of illness (dd/mm/yyyy)
phone
> ANSWER Q3 & Q4
Specify:
phone
> ANSWER Q3 & Q4
phone
> ANSWER Q3 & Q4
> ANSWER Q1, Q3 & Q4
> ANSWER Q3 & Q4
phone
> ANSWER Q1
> ANSWER Q3 & Q4
phone
phone
phone
phone
phone
phone
> ANSWER Q1, Q3 & Q4
> ANSWER Q2
phone
phone
phone
phone
Specify:
> ANSWER Q4
> ANSWER Q3 & Q4
phone
> ANSWER Q3 & Q4
phone
phone
phone
> ANSWER Q2
phone
Specify:
phone
> ANSWER Q2
Specify:
phone
> ANSWER Q2
phone
> ANSWER Q2 & Q4
phone
> ANSWER Q3 & Q4
> ANSWER Q2
> ANSWER Q2
> ANSWER Q1, Q3 & Q4
phone
phone
> ANSWER Q1, Q3 & Q4
phone
> ANSWER Q2
phone
phone
phone
> ANSWER Q2
> ANSWER Q2
> ANSWER Q1, Q3 & Q4
phone
phone
>ANSWER Q1, Q3 & Q4
Q1 Has the case been exposed to swimming pools, a potentially unsafe food, water, raw milk, or food outlet?
Specify:
Q2 Vaccination status for disease notified?
Year vaccinated and type:
Q3 Has the case travelled recently? (SA/interstate/overseas)
Specify:
Q4 Geographic location where the infection was acquired?
Specify:
C CLINICAL COMMENTS (Include others ill)
Note Please inform the person/caregiver you have notified SA Health
D DOCTOR DETAILS
Title
Last Name
Given Name
Provider ID
Address
Suburb Postcode
Contact Number
Laboratory
Other