‎PHAC Case Report Form

Report of Adverse Event (Reaction) Following Immunization

Instructions for Clinicians and Pharmacists:

Health care providers including physicians and pharmacists are required by law to report Adverse Events Following Immunization (AEFI) to monitor vaccine safety. Please complete the AEFI Report Form and send it to the local health unit (see Where to submit an AEFI report).

AEFI report form - short version

Instructions for Public Health:

Data from the form are to be entered into Panorama or PARIS by public health staff. Additional information collection may be required for public health reporting (contained in the AEFI report form long version below) is available. Criteria for reporting and management of adverse events are found in the BC Communicable Disease Control Manual, Chapter 2: Immunization, Part 5.

AEFI report form - long version (for use by public health)

Part 5 - Adverse Events Following Immunization

AEFI Data Entry Guidelines 

The following resource is intended for BC health care providers completing the AEFI case report form or the Panorama AEFI form: User Guide for Completion and Submission of Adverse Events Following Immunization (AEFI) Reports.

Worksheet for Events Managed as Anaphylaxis Following Immunization

Anaphylaxis Worksheet

Events managed as anaphylaxis following immunization may be recorded on this BCCDC worksheet. This worksheet should be completed by the immunizing health care professional that observed and treated the client who experienced the anaphylactic episode. Management guidelines for these events are found in the BC Communicable Disease Control Manual, Chapter 2: Immunization.

Part 3 - Management of Anaphylaxis in a Non-Hospital Setting

After filling and printing the form, please submit the form to the appropriate Medical Health Officer (MHO) for review. Please also complete a Panorama report on this adverse event.

 BC Case Report Form

Reporting Form 

Confirmed Creutzfeldt-Jakob Disease (CJD) became reportable in BC in March 2007. To facilitate reporting when a case of CJD is confirmed by the National CJD surveillance system (CJD-SS) they will enter case details into the form and send to the attending neurologist. The neurologist will complete additional details and fax to public health to notify medical Health Officer. Please enter the case details into iPHIS and fax the form to Communicable Diseases and Immunization Service, BCCDC at 604-707-2516.

Enteric Provincial Surveillance Form with Panorama Guidance

Release of Consumer Card Information Consent Forms

• Consumer Card Information Consent Form - English
  
• Consumer Card Information Consent Form - French
  
• Consumer Card Information Consent Form - Hindi
  
• Consumer Card Information Consent Form - Punjabi
  
• Consumer Card Information Consent Form - Simplified Chinese
  
• Consumer Card Information Consent Form - Spanish
  
• Consumer Card Information Consent Form - Traditional Chinese
  

Amebiasis

• Follow-up Form
  

AIDS

Case Report Form

AIDS is a reportable disease in British Columbia. AIDS reporting is accomplished by submitting a BC AIDS Case Report Form to the BC Centre for Disease Control, Division of STI/HIV Prevention and Control. If an AIDS-defining illness is diagnosed in an HIV positive patient, please download this form, complete and return by mail to:

The BC Centre for Disease Control 
Division of STI/HIV Prevention and Control 
HIV/AIDS Surveillance Nurse 
655 West 12th Avenue
Vancouver, B.C. V5Z 4R4

Gonorrhea and Chlamydia

• HLTH208 - Confidential Notification of Sexually Transmitted Infection Case Report Form (see below)
  

Gonorrhea and chlamydia are reportable diseases in British Columbia.

If gonorrhea and/or chlamydia are diagnosed within Vancouver Coastal Health Authority, or Fraser Health Authority, please download the following form (H208 – BCCDC), complete and return to: 

Hepatitis B: Acute HBV

• Acute HBV Case Report Form

As of January 1st, 2016, this form should be used by public health nurses for follow-up and surveillance of individuals identified with acute hepatitis B, in accordance with the follow-up practices of each Health Authority.      

HIV

• HIV Case Report Form

HIV is a reportable disease in British Columbia. This surveillance form is intended for use by public health nurses responsible for the follow up, support and management of newly diagnosed HIV positive individuals in their Health Authority. Please download, complete and submit the form to:

HIV Surveillance Services

The BC Centre for Disease Control 

Clinical Prevention Services

Provincial STI/HIV Clinic

655 West 12th Avenue

Vancouver, B.C. V5Z 4R4

Fax: 604 707 5604

• HIV Partner or Contact Information Form

This form can be used by public health nurses as an adjunct to the HIV Case Report Form. It is intended to be used as a support tool or template to guide Partner or Contact notification and services for individuals who have been identified by an index case as being at risk of exposure to HIV during the trace-back period. This form is not to be submitted to BCCDC.

Mpox 

• Surveillance Form

Complete this form for confirmed and probable mpox cases and submit electronically (preferred) or by fax to CDIS 604-707-2516. Cases should also be entered in an electronic data management system for communicable diseases (Panorama/PARIS).

TB Screening Form 

TB Screening Form Documentation Guide

Enterovirus D68

• Enterovirus D68 Case Report Form

• Neurologic Illness Associated with Enterovirus D68 Case Report Form

All lab-confirmed cases of enterovirus D68 (EV-D68) should be entered in an electronic data management system for communicable diseases (Panorama/PARIS). For EV-D68 cases associated with respiratory (non-neurologic) clinical presentation, please use the general ‘Enterovirus D68 Case Report Form’. For EV-D68 cases associated with neurologic illness, please use the ‘Neurologic Illness Associated with Enterovirus D68 Case Report Form’.  Case definitions can be found in the linked forms.

Hepatitis B: Acute HBV

• Acute HBV Case Report Form

As of January 1st, 2016, this form should be used by public health nurses for follow-up and surveillance of individuals identified with acute hepatitis B, in accordance with the follow-up practices of each Health Authority.

Influenza

Influenza Severe Outcome Surveillance (SOS) Case Report Form

Severe cases of influenza can be reported in an electronic data management system for communicable diseases (Panorama/PARIS) at the discretion of regional Health Authorities. Refer to Case Report Form for influenza severe outcome surveillance (SOS) case definitions.

Avian Influenza

Avian Influenza Case Report Form

This form should be used by public health for follow-up and surveillance of individuals identified with avian influenza, in accordance with the follow-up practices of each Health Authority.

Invasive Group A Streptococcus

Case Report Form

Complete this form for every case of invasive group A Streptococcal disease. Submit completed forms to Immunization Programs and Vaccine Preventable Diseases Service, BCCDC by fax (604-707-2515) or e-mail (vpd.epi@bccdc.ca). 

All cases should also be reported in an electronic data management system for communicable diseases (Panorama/PARIS). 

Invasive Haemophilus influenzae type b

Case Report Form

Complete this form for every case of invasive Haemophilus influenzae type b disease. If required, submit completed forms to

Immunization Programs and Vaccine Preventable Diseases Service, BCCDC by fax (604-707-2515) or e-mail (vpd.epi@bccdc.ca). 

All cases should also be reported in an electronic data management system for communicable diseases (Panorama/PARIS). 

Invasive Pneumococcal Disease

Case Report Form

Complete this form for every case of invasive pneumococcal disease AGED 0-16 YEARS. Submit completed forms to Immunization Programs and Vaccine Preventable Diseases Service, BCCDC by fax (604-707-2515) or e-mail (vpd.epi@bccdc.ca). 

All cases should also be reported in an electronic data management system for communicable diseases (Panorama/PARIS). 

Measles, Mumps & Rubella 

Measles Case Report Form
Mumps Case Report Form
Rubella Case Report Form

Congenital Rubella 

Case Report Form

Complete a form for every case of measles, mumps or rubella disease. Submit completed forms to Immunization Programs and Vaccine Preventable Diseases Service, BCCDC by fax (604-707-2515) or e-mail (vpd.epi@bccdc.ca).

All cases should also be reported in an electronic data management system for communicable diseases (Panorama/PARIS).

Invasive Meningococcal Disease

Case Report Form

Complete this form for every case of invasive meningococcal disease. Submit completed forms to Immunization Programs and Vaccine Preventable Diseases Service, BCCDC by fax (604-707-2515) or e-mail (vpd.epi@bccdc.ca). 

All cases should also be reported in an electronic data management system for communicable diseases (Panorama/PARIS). 

Pertussis

Minimum data elements for provincial reporting for all probable and confirmed cases of pertussis should be reported in an electronic data management system for communicable diseases (Panorama/PARIS). For VCH only, completed forms should be faxed to Immunization Programs and Vaccine Preventable Diseases Service, BCCDC, at 604-707-2516.

Case Report Form

Contact Management and Treatment forms are provided for use within Health Authorities. These forms do not need to be submitted to BCCDC.

Contact Management Form
Pertussis Forms
Treatment Form 

Other Vaccine Preventable Diseases

Case Report Form

Complete a form for every case of poliomyelitis, tetanus, and for every case and carrier of toxigenic diphtheria.  

Enter reportable cases into Panorama or PARIS.  If required, submit completed forms to Immunization Programs and Vaccine Preventable Diseases Service, BCCDC by fax (604-707-2515) or e-mail (vpd.epi@bccdc.ca).

Inter-Jurisdictional Notification - For use regarding enteric, zoonotic, and vector-borne diseases

• Follow-up Form
  
• Complete this form for inter-jurisdictional notifications that may require additional information, for example notification of a case or contact, or other circumstances requiring public health follow up. A separate form must be completed for each case or contact. Please provide as much information as is available and submit using the instructions in the form.
  

Legionella

• Follow-up Form
  

Lyme Disease

• Surveillance Form
  

Rabies

• Rabies Exposure Report Form
• In case of rabies, immediately contact the on-call person in Communicable Diseases and Immunization Service at 604-707-2510. Refer to the Rabies section in the Communicable Disease Control Manual for management of suspected rabies exposures. 

West Nile Virus

• Case Investigation Report
• This form is to be used in reporting investigations of human cases relating to West Nile Virus. Please fax all completed questionnaires to the Communicable Diseases and Immunization Service, BCCDC at 604-707-2516.

Zika Virus

• Case Report Form