PUBLIC HEALTH AND WELLBEING REGULATIONS 2009 (SR NO 178 OF 2009) - SCHEDULE 6
PUBLIC HEALTH AND WELLBEING REGULATIONS 2009 (SR NO 178 OF 2009) - SCHEDULE 6
Sch. 6
NOTIFICATION BY MEDICAL PRACTITIONERS
FOR GROUP A AND GROUP B NOTIFIABLE CONDITIONS—STRICTLY CONFIDENTIAL
1. Diagnosis
2. Identification
Family Name:
Given Name:
Date of birth:
Sex:
Indigenous status:
Country of birth:
If born overseas, year of arrival in Australia:
Alive/deceased:
3. Other characteristics
Residential Address:
Residential Postcode:
Occupation:
School or childcare attended:
Clinical Comments:
Date of Onset of Illness:
Risk factors:
Suspected mode of transmission:
4. Notifying Doctor
Name:
Address:
Phone Number:
Signature:
Date of report:
5. Timing of notice
Group A
Immediate notification by telephone of an initial diagnosis—whether presumptive or confirmed. Followed by written notification with details of the data elements listed above, within 5 days of the initial diagnosis.
Group B
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Written notification with details of the data elements listed above, within 5 days of the initial diagnosis.
__________________
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FOR GROUP C NOTIFIABLE CONDITIONS—STRICTLY CONFIDENTIAL
1. Diagnosis
2. Identification
Name Code (First two letters of family name, First two letters of given name):
Date of birth:
Sex:
Indigenous status:
Country of birth:
If born overseas, year of arrival in Australia:
Alive/deceased:
3. Other characteristics
Residential Postcode:
Clinical Comments:
Risk factors:
Suspected mode of transmission:
Date of Onset of Illness:
4. Notifying Doctor
Name:
Address:
Phone Number:
Signature:
Date of report:
5. Timing of notice
Written notification with details of the data elements listed above, within 5 days of the initial diagnosis.
__________________
Sch. 6
FOR GROUP D NOTIFICATION FOR HIV—STRICTLY CONFIDENTIAL
1. Identification
Name Code (First two letters of family name, First two letters of given name):
Date of birth:
Sex:
2. Other characteristics
Country of birth:
Indigenous status:
If born overseas, year of arrival in Australia:
Language other than English spoken at home:
Residential postcode:
Date of onset of illness:
3. Notifying doctor
Name:
Address:
Hospital name (if appropriate):
Phone number:
Signature:
Date of notification:
4. Reason for testing
Exposure risk (see section 6):
Investigation of clinical symptoms:
Screening—
Blood, organ or semen donor:
Immigration:
Antenatal:
Confirmation of HIV positive status:
Other:
5. Diagnosis
Date of first diagnosis of HIV infection:
State/Territory of first diagnosis of HIV infection:
CD4+ count or viral load at first diagnosis of HIV infection or both:
History of HIV seroconversion illness:
Date of HIV seroconversion illness:
Has the person had a previous HIV test:
Date of last test:
Result of last HIV test:
Source of information on last test, patient, doctor or laboratory:
6. Exposure category
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Note: More than one exposure category may be notified.
Sexual exposure
Note: At least one of the following must be notified.
Sexual contact only with person of same sex:
Sexual contact with both sexes (if female see section 6a):
Sexual contact only with person of opposite sex (see section 6a):
Sexual contact with a person from another country (write country):
No sexual contact:
Sexual exposure not known:
Vertical exposure
Mother with/at risk of HIV infection:
Blood exposure
Injecting drug use (detail):
Recipient of blood, blood products or tissue (detail):
Haemophilia/coagulation disorder (detail):
6a. Sexual contact
Note: At least one of the following must be answered if MALE reports sexual contact with person of opposite sex or if FEMALE reports sexual contact with either same or OPPOSITE sex.
Sex with bisexual male (women only):
Sex with injecting drug user:
Sex with person from another country (write country):
Sex with a person who received blood, blood products or tissue:
Sex with a person with haemophilia/ coagulation disorder:
Sex with person with HIV infection whose exposure is other than those above (specify):
Heterosexual contact not further specified:
7. Donation of blood or other bodily
fluid or tissue prior to HIV diagnosis
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Note: If this item is applicable, specify type of donation, date and place of donation.
8. Timing of Notice
Written notification with details of the data elements listed in items 1 to 7, within 5 days of the initial diagnosis.
__________________
Sch. 6
FOR GROUP D NOTIFICATION FOR AIDS—STRICTLY CONFIDENTIAL
1. Identification
Name Code (First two letters of family name, First two letters of given name):
Date of birth:
Sex:
2. Other characteristics
Country of birth:
Indigenous status:
Residential postcode:
If born overseas, year of arrival into Australia:
Language other than English spoken at home:
Current state of person—
If person is alive, date of most recent contact:
If person has died, date of death:
3. Notifying doctor
Name:
Address:
Hospital name (if appropriate):
Phone number:
Signature:
Date of notification:
4. Diagnosis
Date of AIDS diagnosis:
Has the person previously been diagnosed with AIDS elsewhere? Yes/No/Unknown
If yes and diagnosis was in another State/Territory, specify State/Territory and date:
If yes and diagnosis was overseas, specify country and date:
5. Laboratory tests
Date of first diagnosis of HIV infection:
CD4+ count or viral load at AIDS diagnosis or both:
Date of specimen collection for CD4+ count analysis:
Note: The CD4+ count and viral load results need to be forwarded as part of your notification when the count and results are available.
6. Anti-retroviral therapy
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Has the person been treated with anti-retroviral therapy?
If yes, specify month/year when started:
7. Diseases indicative of AIDS at diagnosis
Note: At least one of the following must be notified. State whether definite or presumptive.
Pneumocystis carinii pneumonia:
Oesophageal candidiasis:
Kaposi's sarcoma (specify site):
Herpes simplex virus of >1 month duration (specify site):
Cryptococcosis (specify site):
Cryptosporidiosis (diarrhoea >1 month):
Toxoplasmosis (specify site):
Cytomegalovirus (specify site):
Atypical Mycobacteriosis (specify type):
Pulmonary tuberculosis:
Extrapulmonary tuberculosis:
Lymphoma:
Non-Hodgkin's lymphoma, primary of brain/CNS:
Non-Hodgkin's lymphoma, other site (specify type):
HIV encephalopathy (includes AIDS Dementia Complex):
HIV wasting syndrome:
Invasive cervical cancer:
Recurrent pneumonia:
Other (specify):
8. Exposure category
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Note: More than one exposure category may be notified.
Person was interviewed in relation to exposure:
*Not at all (provide reasons):
*To a certain extent (provide the following details):
*In depth (provide the following details):
*Delete if inapplicable
Sexual exposure
Note: At least one of the following must be notified.
Sexual contact only with person of same sex:
Sexual contact with both sexes (if female see section 8a):
Sexual contact only with person of opposite sex (see section 8a):
Sexual contact with a person from another country (write country):
No sexual contact:
Sexual exposure not known:
Vertical exposure
Mother with/at risk of HIV infection:
Blood exposure
Injecting drug use (detail):
Recipient of blood, blood products or tissue (detail):
Haemophilia/coagulation disorder (detail):
Other exposure
Exposures other than those above apply (provide details):
Exposure could not be established (detail):
8a. Sexual contact
Note: At least one of the following must be answered if MALE reports sexual contact with person of opposite sex or if FEMALE reports sexual contact with either same or OPPOSITE sex.
Sex with bisexual male (women only):
Sex with injecting drug user:
Sex with person from another country (write country):
Sex with a person who received blood, blood products or tissue:
Sex with a person with haemophilia/coagulation disorder:
Sex with person with HIV infection whose exposure is other than those above (specify):
Sex with person with HIV infection whose exposure could not be established:
Heterosexual contact not further specified:
9. Timing of Notice
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Written notification with details of the data elements listed in items 1 to 8a, within 5 days of the initial diagnosis.
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