Ontario CPE Investigation Tool Legend ♦ for interview with case System-Mandatory Required Personal Health Information Cover Sheet 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: 1: Email 2: Address: ______________________________________________ ♦ Reported Date: Diagnosing Health Unit: Tel. 1: ♦ Disease: CPE - COLONIZATION CPE - INFECTION CPE - UNSPECIFIED TYPE: HOME MOBILE WORK
Ontario CPE Investigation Tool Legend for interview with case ♦ System-Mandatory Required Personal Health Information Cover Sheet Date Printed: Bring Forward Date: iPHIS Client ID #: ♦ Gender: ______________ ♦ Age: ________________________ ♦ Investigator: ♦ DOB: __________________________________________ ♦ Branch Office: Address: ______________________________________________ ♦ Reported Date: Diagnosing Health Unit: Tel. 1: ♦ Disease: CPE - COLONIZATION CPE - INFECTION CPE - UNSPECIFIED TYPE: HOME MOBILE WORK ♦ Client Name: Alias: ♦ Gender: ♦ Age: ♦ DOB: Address: Tel. 1: Type: Home Mobile Work Tel. 2: Type: Home Mobile Work 1: Email 2:
CPE%20Investigation%20Tool.docx