Ontario Infant Botulism Investigation Tool ♦ for interview with case System-Mandatory Required Personal Health Information Legend Cover Sheet Note that this page can be autogenerated in iPHIS Date Printed: Client Name: ♦ Bring Forward Date: Alias: iPHIS Client ID #: Gender: Age: ♦ ♦ DOB: ♦ Gender: ______________ Age: ♦ ♦ Address: ________________________ Investigator: ♦ Tel. 1: Type: Home Mobile Work DOB: ♦ Tel. 2: __________________________________________ Type: Home Mobile Work Branch Office: ♦ Email 1: Email 2: Address: ______________________________________________ Reported Date: ♦ Diagnosing Health Unit: Tel. 1: Disease: BOTULISM ♦ Type: Home Mobile Work Is this an outbreak associated case? ♦ Other, please specify: _____________________________
Ontario Infant Botulism Investigation Tool Legend for interview with case ♦ System-Mandatory Required Personal Health Information Cover Sheet Note that this page can be autogenerated in iPHIS Date Printed: Bring Forward Date: iPHIS Client ID #: ♦ Gender: ______________ ♦ Age: ________________________ ♦ Investigator: ♦ DOB: __________________________________________ ♦ Branch Office: Address: ______________________________________________ ♦ Reported Date: Diagnosing Health Unit: Tel. 1: ♦ Disease: BOTULISM Type: Home Mobile Work ♦ Is this an outbreak associated case? Other, please specify: _____________________________ ♦ Client Name: Alias: ♦ Gender: ♦ Age: ♦ DOB: Address: Tel. 1: Type: Home Mobile Work Tel. 2: Type: Home Mobile Work Email 1: Email 2:
Botulism%20Infant%20Investigation%20Tool.docx