SURVEILLANCE FORMS

Where indicated, please forward case report forms to:

SURVEILLANCE GUIDELINES Surveillance Forms General (Last updated October 2021) Page 1 of 1

General Reporting

• Nova Scotia Notifiable Disease Surveillance Case Report Form

Attach to disease specific case report form.

• Physician's Communicable Disease Report Form

Completed by physicians reporting a notifiable disease case and sent to the local Public Health Services office.

• Daycare Surveillance Reporting Tool

Completed case forms should be filed according to NSHA procedures. For further information contact 902-424-6567.

• School Surveillance Reporting Tool

Completed case forms should be filed according to NSHA procedures. For further information contact 902-424-6567.

• School and Daycare Absenteeism Flow Chart

For reference purposes.

Mailing Address: Department of Health and Wellness Population Health Assessment and SurveillanceSurveillance Team PO Box 488 Halifax, NS B3J 2R8

Note: Please ensure envelope is labeled ‘MEDICAL CONFIDENTIAL’

Confidential Fax#: 902-424-0550

E-mail: Surveillance Epi Content Leadcc: Administrative Support

via Secure File Transfer (only)

SURVEILLANCE FORMS

Where indicated, please forward case report forms to:

SURVEILLANCE GUIDELINES Surveillance Forms AEFIs (Last updated October 2021) Page 1 of 1

Adverse Events Following Immunization (AEFI)

• Adverse Events Following Immunization (AEFI) PHAC Form Report of adverse events following immunization (AEFI) (canada.ca)

Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax. For further information contact 902-424-6567.

• Adverse Events Following Immunization (AEFI) User’s Guide Reporting Adverse Events Following Immunization (AEFI) in Canada: User guide to completion and submission of the AEFI reports - Canada.ca

Guidelines for completion of Adverse Events Following Immunization (AEFI) Case Report Form

Mailing Address: Department of Health and Wellness Surveillance Team PO Box 488 Halifax, NS B3J 2R8

Note: Please ensure envelope is labeled ‘MEDICAL CONFIDENTIAL’

Confidential Fax#: 902-424-0550

E-mail: Surveillance Epi Content Leadcc: Administrative Support

via Secure File Transfer (only)

SURVEILLANCE FORMS

Where indicated, please forward case report forms to:

SURVEILLANCE GUIDELINES Surveillance Forms BBP (Last updated Apr 2016) Page 1 of 1

Bloodborne Pathogens

• Hepatitis B, Hepatitis C Case Report Form

Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax. For further information contact 902-424-5940.

• Hepatitis B and C Congenital Case Report Form

Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax. For further information contact 902-424-5940.

• HIV/AIDS National Case Report Form Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax. For further information and to obtain hard copies of this form, contact 902-424-5940.

• HIV Strain and Drug Resistance Surveillance Case Report Form

Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax. For further information contact 902-424-5940.

• Post Exposure to Bloodborne Pathogens Form

Completed case forms should be filed according to NSHA procedures. For further information contact 902-424-5940.

Mailing Address: Department of Health and Wellness Population Health Assessment and SurveillanceSurveillance Team PO Box 488 Halifax, NS B3J 2R8

Note: Please ensure envelope is labeled ‘MEDICAL CONFIDENTIAL’

Confidential Fax#: 902-424-0550

E-mail: Surveillance Epi Content Leadcc: Administrative Support

via Secure File Transfer (only)

SURVEILLANCE FORMS

Where indicated, please forward case report forms to:

SURVEILLANCE GUIDELINES Surveillance Forms Direct Contact (Last updated Apr 2016)

Page 1 of 2

Direct Contact, Respiratory Routes, and Through the Provision of Health Care

• CJD/vCJD Case Report Form Completed case forms for variant CJD must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax as soon as possible. Completed case forms for cases of classic CJD must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax. For further information contact 902-424-6567.

• Ebola Case Report Form (Public Health Agency of Canada)

Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax immediately after initial report is completed or as requested. For further information contact 902-424-6567. NOTE: Please complete as much detail as possible on this form at the time of the initial report. It is not expected that all fields will be completed during the initial report, but that updates will be made when information becomes available.

• Ebola Virus Disease Monitoring Form Completed forms should be filed according to NSHA procedures. For further information contact 902-424-6567.

• Ebola Virus Disease Contacts Form Completed forms should be filed according to NSHA procedures. For further information contact 902-424-6567.

• Ebola Virus Disease Traveler Monitoring Form Completed forms should be filed according to NSHA procedures. For further information contact 902-424-6567.

Mailing Address: Department of Health and Wellness Population Health Assessment and SurveillanceSurveillance Team PO Box 488 Halifax, NS B3J 2R8

Note: Please ensure envelope is labeled ‘MEDICAL CONFIDENTIAL’

Confidential Fax#: 902-424-0550

E-mail: Surveillance Epi Content Leadcc: Administrative Support

via Secure File Transfer (only)

SURVEILLANCE GUIDELINES Surveillance Forms Direct Contact (Last updated Apr 2016)

Page 2 of 2

Direct Contact, Respiratory Routes, and Through the Provision of Health Care

• Emerging Respiratory Pathogens and Severe Acute Respiratory Infection (SARI) Case Report Form

Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax. For further information contact 902-424-6567.

• ER ICP ILI Surveillance Weekly Report Form Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax or e-mail SURVEILLANCEDHW@novascotia.ca. For further information contact 902-424-6567.

• Invasive Group A Streptococcal Disease Case Report Form

Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax. For further information contact 902-424-6567

• Influenza Case Report Form with Data Dictionary

Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax. For further information contact 902-424-6567

• LTCF Residents: Influenza Surveillance Line Listing

Completed line listings should be filed according to NSHA procedures. For further information contact 902-424-6567.

• LTCF Staff: Influenza Surveillance Line Listing

Completed line listings should be filed according to NSHA procedures. For further information contact 902-424-6567.

• Other Disease Case Report Form Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax as soon as possible for the following: Group B Streptococcal Disease of Newborn Legionellosis Leprosy (Hansen’s Disease) Severe Acute Respiratory Syndrome (SARS) Viral Hemorrhagic Fevers (except Ebola) Otherwise, completed case forms should be filed according to NSHA procedures. Case report forms may be requested by the DHW Surveillance Team if further investigation is required. For further information contact 902-424-6567.

SURVEILLANCE GUIDELINES Surveillance Forms Influenza (Last updated Sept 2018) Page 1 of 1

Seasonal Influenza Vaccine Data Collection

• Clinic Line List

For clinic use.

• Long Term Care Line List

For Long Term Care (nursing home and residential care facility) use.

• Public Health Aggregate Data

For public health clinic use. For further information contact 902-424-6567.

• Health Care Facilities Immunizing Staff/Volunteers (excluding LTC/RCF)

For facility use. For further information contact your local public health office.

• Long Term Care/Residential Care Facilities

For long term care/residential care facility use. For further information contact your local public health office.

• All other Facilities or Clinics (non-PH and Non-Health Care Facilities)

For facility/clinic use. For further information contact your local public health office.

• Seasonal Influenza Immunization Summary Sheet

For NSHA public health services use. For further information contact 902-424-6567.

Mailing Address: Department of Health and Wellness Population Health Assessment and SurveillanceSurveillance Team PO Box 488 Halifax, NS B3J 2R8

Note: Please ensure envelope is labeled ‘MEDICAL CONFIDENTIAL’

Confidential Fax#: 902-424-0550

E-mail: Surveillance Epi Content Leadcc: Administrative Support

via Secure File Transfer (only)

SURVEILLANCE GUIDELINES Surveillance Forms Enteric (Last updated July 2017) Page 1 of 2

Enteric, Foodborne and Waterborne

• Campylobacter Case Report Form Completed case forms should be filed according to NSHA procedures. Case report forms may be requested by the NSHA Surveillance Team if further investigation is required. For further information contact 902-424-6567.

• Cryptosporidiosis Case Report Form Completed case forms should be filed according to NSHA procedures. Case report forms may be requested by the DHW Surveillance Team if further investigation is required. For further information contact 902-424-6567.

• Enteric Case Report Form Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax for the following: Botulism (Foodborne, Wound, Infant, & Colonization Botulism) Cholera Shellfish Poisoning (Paralytic & Amnesic) Typhoid Otherwise, completed case forms should be filed according to NSHA procedures. Case report forms may be requested by the DHW Surveillance Team if further investigation is required. For further information contact 902-424-6567.

Mailing Address: Department of Health and Wellness Population Health Assessment and SurveillanceSurveillance Team PO Box 488 Halifax, NS B3J 2R8

Note: Please ensure envelope is labeled ‘MEDICAL CONFIDENTIAL’

Confidential Fax#: 902-424-0550

E-mail: Surveillance Epi Content Leadcc: Administrative Support

via Secure File Transfer (only)

SURVEILLANCE GUIDELINES Surveillance Forms Enteric (Last updated July 2017) Page 2 of 2

Enteric, Foodborne and Waterborne

• Giardiasis Case Report Form Completed case forms should be filed according to NSHA procedures. Case report forms may be requested by the DHW Surveillance Team if further investigation is required. For further information contact 902-424-6567.

• Hepatitis A Case Report Form Completed case forms should be filed according to NSHA procedures. Case report forms may be requested by the NSHA Surveillance Team if further investigation is required. For further information contact 902-424-6567.

• Listeria (Invasive) Questionnaire PHAC Form

Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax. For further information contact 902-424-6567.

• Salmonellosis Case Report Form Completed case forms should be filed according to NSHA procedures. Case report forms may be requested by the DHW Surveillance Team if further investigation is required. For further information contact 902-424-6567.

• Shigellosis Case Report Form Completed case forms should be filed according to NSHA procedures. Case report forms may be requested by the DHW Surveillance Team if further investigation is required. For further information contact 902-424-6567.

• Verotoxigenic E.coli Case Report Form Completed case forms should be filed according to NSHA procedures. Case report forms may be requested by the DHW Surveillance Team if further investigation is required. For further information contact 902-424-6567.

SURVEILLANCE GUIDELINES Surveillance Forms STIs (Last updated Apr 2016) Page 1 of 1

Sexually Transmitted Infections

• Sexually Transmitted Infections Case Report Form Completed case forms should be filed according to NSHA procedures. Case report forms may be requested by the DHW Surveillance Team if further investigation is required. For further information contact 902-722-1494.

• Syphilis Case Report Form Completed case forms should be filed according to NSHA procedures. Case report forms may be requested by the DHW Surveillance Team if further investigation is required. For further information contact 902-722-1494.

• STI Contact Follow-up Form Completed forms should be filed according to NSHA procedures. Forms may be requested by the DHW Surveillance Team if further investigation is required. For further information contact 902-722-1494.

Mailing Address: Department of Health and Wellness Population Health Assessment and SurveillanceSurveillance Team PO Box 488 Halifax, NS B3J 2R8

Note: Please ensure envelope is labeled ‘MEDICAL CONFIDENTIAL’

Confidential Fax#: 902-424-0550

E-mail: Surveillance Epi Content Leadcc: Administrative Support

via Secure File Transfer (only)

SURVEILLANCE GUIDELINES Surveillance Forms Tuberculosis (Last updated Apr 2016) Page 1 of 1

Sporadic Communicable Disease in Returning Travelers

• Sporadic Communicable Disease in Returning Travelers Case Report Form

Completed case form must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax. For further information contact 902-424-6567.

Mailing Address: Department of Health and Wellness Population Health Assessment and SurveillanceSurveillance Team PO Box 488 Halifax, NS B3J 2R8

Note: Please ensure envelope is labeled ‘MEDICAL CONFIDENTIAL’

Confidential Fax#: 902-424-0550

E-mail: Surveillance Epi Content Leadcc: Administrative Support

via Secure File Transfer (only)

SURVEILLANCE GUIDELINES Surveillance Forms Tuberculosis (Last updated Apr 2016) Page 1 of 1

Where indicated, please forward case report forms to:

Mailing Address: Department of Health and Wellness Population Health Assessment and Surveillance Surveillance Team PO Box 488 Halifax, NS B3J 2R8

Note: Please ensure envelope is labeled ‘MEDICA CONFIDENTIAL’

Confidential Fax#: 902-424-0550

E-mail: Surveillance Epi Content Lead

cc: Administrative Support

via Secure File Transfer (only)

L

Tuberculosis (TB)

• Tuberculosis Case Report Form Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax. For further information contact 902-424-6567.

• Tuberculosis Contact Form Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax. For further information contact 902-424-6567.

• Tuberculosis Contact Line List Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax. For further information contact 902-424-6567.

• Tuberculosis Directly Observed Therapy

Record

Completed case forms should be filed according to NSHA P rocedures. For further information contact 902-424-6567.

• Tuberculosis Case Treatment Monthly Monitoring Form

Completed case forms should be filed according to NSHA P rocedures. For further information contact 902-424-6567.

• Tuberculosis Contact Chemoprophylaxis Monthly

Monitoring Form (Isoniazid only)

Completed case forms should be filed according to NSHA P rocedures. For further information contact 902-424-6567.

• Tuberculosis Contact Chemoprophylaxis Monthly

Monitoring Form (Rifampin only)

Completed case forms should be filed according to NSHA P rocedures. For further information contact 902-424-6567.

• Tuberculosis Medical Surveillance Follow-up Form Completed case forms should be filed according to NSHA P rocedures. For further information contact 902-424-6567.

• Canadian Tuberculosis and Air Travel PHAC Form:

http://www.phac-aspc.gc.ca/tbpc-

latb/pdf/tbform_aircraft09.pdf

Completed case report forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax. For further information contact 902-424-6567.

SURVEILLANCE GUIDELINES Surveillance Forms Tuberculosis (Last updated Apr 2016) Page 1 of 1

• Canadian Tuberculosis and Air Travel Guidelines http://www.who.int/tb/publications/2008/WH O_HTM_TB_2008.399_eng.pdf

Guidelines for completion of Canadian Tuberculosis and Air Travel Reporting Form

• Active Tuberculosis New and Re-treatment PHAC Form http://www.phac-aspc.gc.ca/tbpc- latb/pdf/atcrform-eng.pdf

Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax. For further information contact 902-424-6567.

• Treatment Outcome of a New Active or Re-treatment Tuberculosis PHAC Form http://www.phac-aspc.gc.ca/tbpc- latb/pdf/torform-eng.pdf

Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax. For further information contact 902-424-6567.

• Active Tuberculosis New and Re-treatment Cases and Treatment Outcome of a New Active or Re-treatment Case Guidelines http://www.phac-aspc.gc.ca/tbpc- latb/pdf/guidelinesform-eng.pdf

Guidelines for completion of Active Tuberculosis New and Re- treatment Case and Treatment Outcome of a New Active or Re- treatment Tuberculosis.

SURVEILLANCE FORMS

Where indicated, please forward case report forms to:

SURVEILLANCE GUIDELINES Surveillance Forms VPD (Last updated Apr 2016) Page 1 of 1

Vaccine Preventable Diseases

• Vaccine Preventable Case Report Form (except Measles, Mumps and Rubella)

Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax for the following:

Acute Flaccid Paralysis Diphtheria Poliomyelitis Smallpox Otherwise, completed case forms should be filed according to NSHA procedures. Case report forms may be requested by the DHW Surveillance Team if further investigation is required. For further information contact 902-424-6567.

• Measles, Mumps and Rubella Case Report Form

Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax for the following:

Measles Mumps Rubella Otherwise, completed case forms should be filed according to NSHA procedures. Case report forms may be requested by the DHW Surveillance Team if further investigation is required. For further information contact 902-424-6567.

Mailing Address: Department of Health and Wellness Population Health Assessment and SurveillanceSurveillance Team PO Box 488 Halifax, NS B3J 2R8

Note: Please ensure envelope is labeled ‘MEDICAL CONFIDENTIAL’

Confidential Fax#: 902-424-0550

E-mail: Surveillance Epi Content Leadcc: Administrative Support

via Secure File Transfer (only)

SURVEILLANCE FORMS

Where indicated, please forward case report forms to:

SURVEILLANCE GUIDELINES Surveillance Forms Vectorborne (Last updated Apr 2017) Page 1 of 1

Vectorborne and Other Zoonoses

• Lyme Disease Case Report Form Completed case forms must be sent to the DHW Surveillance Team via secure file transfer, mail or confidential fax. For further information contact 902-722-1494.

• Rabies Investigation Case Report Form Completed case forms must be sent to the DHW Surveillance Team via secure file transfer, mail or confidential fax. For further information contact 902-722-1494.

• West Nile Virus Case Report Form Completed case forms must be sent to the DHW Surveillance Team via secure file transfer, mail or confidential fax. For further information contact 902-722-1494.

• Other Disease Case Report Form Completed case forms must be sent to the DHW Surveillance Team via secure e-mail, mail or confidential fax as soon as possible for the following: Anthrax Hantavirus Pulmonary Syndrome Plague Rabies (Human rabies) Yellow Fever Malaria Otherwise, completed case forms should be filed according to NSHA procedures. Case report forms may be requested by the DHW Surveillance Team if further investigation is required. For further information contact 902-722-1494.

Mailing Address: Department of Health and Wellness Population Health Assessment and SurveillanceSurveillance Team PO Box 488 Halifax, NS B3J 2R8

Note: Please ensure envelope is labeled ‘MEDICAL CONFIDENTIAL’

Confidential Fax#: 902-424-0550

E-mail: Surveillance Epi Content Leadcc: Administrative Support

via Secure File Transfer (only)