Hong Kong Regulations

PREVENTION OF THE SPREAD OF INFECTIOUS DISEASES REGULATIONS - SCHEDULE SCHEDULE

Caution: This is a past version. See the current version here.

[regulation 4]

FORM 1

QUARANTINE AND PREVENTION OF DISEASE ORDINANCE

( Cap 141)

Tuberculosis Notification

Particulars of Infected Person

Name in English: Name in Chinese: Age/Sex: I.D. Card/
Passport No.:

Address: Telephone
Number:

Place of Work/School Attended: Telephone
Number:

Site of TB Sputum
Disposal Resp. System Smear Culture On Treatment Meninges Positive On
Observation Hospital/
Clinic sent to
(if any): Bone & Joint Negative Referred Other(s) Unknown Died
Hospital No.:
Duration of stay in Hong Kong: _______________ Years.

Does patient have a history of past treatment for tuberculosis? □
Yes                        □ No


If yes, please state the YEAR in which he first received treatment:
______________________________________

Notified under the Prevention of the Spread of Infectious Diseases 
Regulations by

Dr. _____________________________________ on _________/_____________/_________
(Full Name in BLOCK Letters) (Date)

Telephone Number: ____________________ ___________________________________
________
(Signature)

(Please DELETE whichever is not applicable)

"I will arrange for examination of contacts myself."

"Please arrange for examination of contacts to be done by the Government Chest
Service."
Further Remarks:

FORM 2

QUARANTINE AND PREVENTION OF DISEASE ORDINANCE

( Cap 141)

Notification of Infectious Diseases other than Tuberculosis

Particulars of Infected Person

Name in English: Name in Chinese: Age/Sex: I.D. Card/
Passport No.:

Address: Telephone Number:

Place of Work/School Attended: Telephone Number:

Hospital(s) attended: Hospital/A & E Number:

Disease (P) below Suspected/Confirmed on _______/_________/_______.

Acute Poliomyelitis Leprosy Rubella
Amoebic Dysentery Malaria Scarlet Fever
Bacillary Dysentery Measles Tetanus
Chickenpox Meningococcal Infections Typhoid Fever
Cholera Mumps Typhus
Dengue Fever Paratyphoid Fever Viral Hepatitis
Diphtheria Plague Whooping Cough
Food Poisoning Rabies Yellow Fever
Legionnaires' Disease Relapsing Fever

Notified under the Prevention of the Spread of Infectious Diseases 
Regulations by

Dr. _____________________________________ on _________/_____________/_________
(Full Name in BLOCK Letters) (Date)

Telephone Number: ____________________
_________________________________________
(Signature)

Remarks:

(L.N. 81 of 1994; L.N. 347 of 1998)