Is this an outbreak associated case? ♦ please specify: _____________________________ Yes, OB # No, link to OB # 0000-2005-009 in iPHIS Is the client in a high-risk occupation/ environment? Yes, specify: No Is the client homeless? Yes No Physician’s Name: ♦ New Address: Role: Attending Physician Family Physician ♦ Specialist Walk-In Physician Other Unknown Language: ♦ OPTIONAL Translation required? Yes No Additional Physician’s Name: respondent Address: Name: Tel: Fax: Parent/Guardian Spouse/Partner Role: Other Verification of Client’s Identity & Notice of Collection Client’s identity verified? Yes, specify: DOB Postal Code Physician No Notice of Collection Please consult with local privacy and legal counsel about PHU-specific Notice of Collection requirements under s. 16. Insert Notice of Collection, as necessary. Record of File Date Investigator’s Investigator’s Designation ♦ ♦ Responsible Investigator’s Signature Initials Health Unit Name Investigation Start Date PHI PHN Other
♦ Is this an outbreak associated case? please specify: _____________________________ Yes, OB # No, link to OB # 0000-2005-009 in iPHIS Is the client in a high-risk occupation/ environment? Yes, specify: No Is the client homeless? Yes No New Address: ♦ Language: Translation required? Yes No respondent Name: Parent/Guardian Spouse/Partner Other ♦ Physician’s Name: ♦ Role: Attending Physician Family Physician Specialist Walk-In Physician Other Unknown OPTIONAL Additional Physician’s Name: Address: Tel: Fax: Role: Verification of Client’s Identity & Notice of Collection Client’s identity verified? Yes, specify: DOB Postal Code Physician No Notice of Collection Please consult with local privacy and legal counsel about PHU-specific Notice of Collection requirements under s. 16. Insert Notice of Collection, as necessary. Record of File ♦ Responsible Health Unit Date ♦ Investigator’s Name Investigator’s Signature Investigator’s Initials Designation Investigation Start Date PHI PHN Other
Cryptosporidiosis%20Investigation%20Tool.docx