Hospitalization, Death, & Severe Respiratory Illness (Sri) Case Report Form printable pdf download

Hospitalization, Death, & Severe Respiratory Illness (Sri) Case Report Form

… SRI Case

… SRI Death

… pH1N1 Hospitalization

… pH1N1 Death

(lab-confirmed)

Appendix IV: Case Report Form (Hospitalizations, Deaths, SRIs)

Patient/Proxy PROTECTED INFORMATION – LOCAL USE ONLY –

DO NOT FORWARD THIS SECTION

PATIENT Contact Information:

Last name: ____________________________________

HOSPITAL Information:

First name: ____________________________________

Name of hospital:____________________________

Usual residential address: ________________________

PROXY Information:

________________________________________________

Is respondent a proxy?

(e.g. for deceased patient, child)

City: ___________________________________________

… No

… Yes (complete information below)

Province/Territory: _____________Postal code: _______

Phone number(s): (_____) ______ - __________________

Proxy Last name: ____________________________

(_____) ______ - __________________

Proxy First name: _______________________________

Proxy Relationship to case: _____________________

Local Contact Information (if different from residential):

Proxy Phone number: (______) ______ - ____________

Phone number: (_____) ______ - ___________________

Number valid until

: _____/______/________

(dd/mm/yyyy)

Please notify your MOH and Kelly Butt (kellybutt@gov.nl.ca) immediately

AND

Send completed forms to your regional CDCN

Revised November 12, 2009

Hospitalization, Death, & Severe Respiratory Illness (Sri) Case Report Form