Hong Kong Regulations

PREVENTION OF THE SPREAD OF INFECTIOUS DISEASES REGULATIONS - SCHEDULE

SCHEDULE

(Past version on 31/12/2004).
(Past version on 16/07/2004).
(Past version on 30/01/2004).
(Past version on 27/03/2003).
(Past version on 01/02/1999).
(Past version on 30/06/1997).



[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
Hospital/

Clinic sent to

(if any):

Resp. System
Smear
Culture
On Treatment


Meninges
Positive
On Observation


Bone & Joint
Negative
Referred
Hospital No.:

Other(s)
Unknown
Died




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
Legionnaires' Disease
Scarlet Fever

Amoebic Dysentery
Leprosy
Severe Acute Respiratory Syndrome

Bacillary Dysentery
Malaria
Streptococcus suis infection

Chickenpox
Measles
Tetanus

Cholera
Meningococcal Infections
Typhoid Fever

Dengue Fever
Mumps
Typhus

Diphtheria
Paratyphoid Fever
Viral Hepatitis

Food Poisoning
Plague
Whooping Cough

Influenza A (H5), Influenza A (H7) 
Rabies
Yellow Fever

or Influenza A (H9)
Relapsing Fever


Japanese encephalitis
Rubella




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; L.N. 80 of 2003; L.N. 15 of 2004; L.N. 138
of 2004; L.N. 224 of 2004; L.N. 131 of 2005)