Get the free Pertussis Notification Fax Form - West Coast DHB

PERTUSSIS NOTIFICATION FAX FORM TO: Community and Public Health ATTENTION: FAX: (03) 379 6484 DATE: CAUTION: Medical Officer of Health The information contained in this facsimile is legally privileged

How to fill out pertussis notification fax form

How to fill out pertussis notification fax form:

1. Start by gathering all the necessary information. You will need the patient's name, date of birth, address, and contact information.
2. Next, fill in the healthcare provider's information. This includes their name, clinic or hospital name, address, and contact details.
3. Fill in the date of symptom onset and the date the diagnosis was made.
4. Indicate whether the patient is a confirmed or suspected case of pertussis.
5. Provide details about the severity of the symptoms and any complications, if applicable.
6. Include information about any treatment given to the patient, such as antibiotics.
7. If the patient has been hospitalized, specify the dates and details of the admission.
8. Finally, sign and date the form before faxing it to the relevant health department or agency.

Who needs pertussis notification fax form:

1. Healthcare providers who diagnose and treat patients with pertussis need to fill out and submit the pertussis notification fax form.
2. Public health agencies and departments require this form to track and monitor the disease, which helps in taking necessary measures to prevent its spread.
3. Schools, childcare facilities, and other institutions may also request this form to ensure the safety of their staff and students by identifying and taking appropriate action in case of a pertussis outbreak.

For pdfFiller’s FAQs

What is pertussis notification fax form?

The pertussis notification fax form is a document used to report cases of pertussis (whooping cough) to the appropriate health authorities.

Who is required to file pertussis notification fax form?

Healthcare providers and facilities are required to file the pertussis notification fax form when they diagnose a case of pertussis.

How to fill out pertussis notification fax form?

The pertussis notification fax form must be filled out with the patient's personal information, symptoms, test results, and treatment information.

What is the purpose of pertussis notification fax form?

The purpose of the pertussis notification fax form is to notify public health officials of cases of pertussis in order to prevent the spread of the disease.

What information must be reported on pertussis notification fax form?

The pertussis notification fax form must include the patient's name, age, address, symptoms, test results, treatment received, and contact information for the healthcare provider.

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