Surveillance Forms

The following surveillance forms have been approved by the Minister of Health for reporting and public health investigation and may be downloaded by clicking on the links below.

Note: All documents on this page are in Adobe Acrobat format PDF unless otherwise indicated. 

Form Number

Category / Form Name

User Guide

Last Update

 

Communicable Diseases

 

 

Documenting Geography for Communicable Disease Investigations in PHIMS

 

April 2019

MHSU-6638

Notification of No Follow-Up Form

Instructions

2019-04-18

MHSU-0013

Clinical Notification of Reportable Diseases or Conditions

 

MHSU-0002

Communicable Disease Control Investigation Form

Instructions

2019-06-24

 

Sexually-Transmitted and Blood-Borne Pathogens

 

User Guide for Completion of Surveillance Forms for Reportable Diseases

Overall User Guide

October 2019

MHSU-6784

STI Case Investigation Form For Chlamydia, Gonorrhea, Chancroid and LGV Infections – Case Form

Instructions

2018-08-29

MHSU-6782

STBBI Contact Investigation Form – Contact Form

Instructions

2018-08-29

MHSU-6780

Hepatitis B and C, HIV, and Syphilis Investigation Form – Case Form

Instructions

2019-07-24

MHSU-2667

Congenital Syphilis Investigation Form

Instructions

2019-10-21

MHSU-4482

HIV Case Report Form for Anonymous Testing

 

2008-04-01

MHSU-4487

HIV Case Report Form for Rapid HIV Testing

 

2008-04-01

MHSU-2437

HIV/AIDS Case Report – use for reporting AIDS cases only

 

 

Vaccine Preventable Diseases

 

MHSU-8733

Vaccine Preventable Disease Investigation Form

Instructions

2019-06-24

 

Immunization

 

MHSU-2234

Reporting of Adverse Events Following Immunization (AEFI)

User Guide to Completion and Submission of the AEFI Reports

IIFHCP

Immunization Input Form for Health Care Providers

 

January 2017

 

Respiratory Diseases

 

MHSU-7274

Severe Acute Respiratory Infection (SARI) and Emerging Respiratory Pathogens – Case Report Form

Emerging Respiratory Pathogens (Public Health Agency of Canada)

 

Weekly Reporting Template for Hospitalizations, ICU Admissions, and Deaths with Laboratory-Confirmed Influenza: 2018/2019 Season

Reporting Requirements for Severe Outcomes Associated with Laboratory Confirmed Influenza: 2018/2019 Season

 

Opioid Overdose and Misuse Surveillance

 

MHSU-6836

Overdose Response Form

 

2017-11-15

MHSU-6259

Take-Home Naloxone Kit Tracking Reporting Form

 

2017-11-15

 

Enteric, Food and Water-borne Diseases

 

MHSU-3265

Enhanced Surveillance E. Coli O157: H7 Questionnaire

 

2010-08-01

MHSU-7256

Salmonella Questionnaire - General

 

MHSU-4372

Hepatitis A Questionnaire

 

MHSU-5478

Invasive Listeriosis Questionnaire

 

 

Vector-borne and Other Zoonotic Diseases

MHSU-8232

Tick-Borne Disease Clinical Case Report Form

Instructions

2018-08-28

MHSU-9684

West Nile virus Human Case Investigation Form

Instructions

2019-06-24

MHSU-7224

Report of Suspected Rabies Exposure

 

2016-10-01

 

Outbreaks

 

 

Enteric Outbreak Summary Report AND Respiratory/Vaccine Preventable Disease Outbreak Summary Report

 

 

For CNPHI Users: Login to CNPHI and enter enteric or respiratory/vaccine preventable disease outbreak summary

 

 

For non-CNPHI Users: Please contact the local public health CNPHI writer, or download the forms and report directly to Epidemiology & Surveillance, Public Health, Manitoba Health, Seniors and Active Living.

 

MHSU-6236

Enteric Outbreak Summary Report

 

MHSU-6287

Vaccine Preventable and Respiratory Infections Outbreak Summary Report

 

MHSU-6278

Outbreak Summary Report (NOT Enteric or Respiratory/Vaccine Preventable Disease Outbreaks)

 

 

Outdated Forms No Longer Being Accepted

Please Use Instead:

MHSU-4228

Hepatitis B and C Case Investigation Form

MHSU-6780
Hepatitis B and C, HIV, and Syphilis Investigation Form – Case Form

MHSU-4486

HIV Case Investigation Form for Nominal and Non-Nominal Positive Cases

MHSU-6780
Hepatitis B and C, HIV, and Syphilis Investigation Form – Case Form

MHSU-6787

Mumps Case Investigation Form

MHSU-8733
Vaccine Preventable Disease Investigation Form for Diphtheria, H. Influenzae, Meningococcal, Measles, Mumps, Pertussis, Rubella, and Tetanus cases – Case Form

MHSU-7974

Syphilis Case Investigation Form

MHSU-6780
Hepatitis B and C, HIV, and Syphilis Investigation Form – Case Form

 

HIV Contact Notification Form

MHSU-6782
STBBI Contact Investigation Form – Contact Form

 

Syphilis Contact Investigation Form

MHSU-6782
STBBI Contact Investigation Form – Contact Form

 

Notification of Sexually-Transmitted Disease Form

MHSU-6784
STI Case Investigation Form For Chlamydia, Gonorrhea, Chancroid and LGV Infections – Case Form

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Immunization Tariff Codes

In Manitoba, immunization tariff codes serve two important functions:

  1. To link an immunizing agent provided by a health care provider to an individual's immunization record in the Manitoba Immunization Monitoring System (MIMS).
  2. To remunerate physicians for immunizations provided via the physician billing system of the Insured Benefits Branch of Manitoba Health, Seniors and Active Living.

For a list of all current and cancelled tariff codes in MIMS, four options are available as follows:

  1. For MIMS Users - select the Inquire General Table Information from the Operator Primary Menu, then select - Inquire Immunization Table.
  2. For a hard copy - complete the MIMS: Immunization Table Listing form MS Word (to ensure any updates are received, hard copies should be replaced on a regular basis).
  3. Contact a MIMS user at the nearest local Public Health office.
  4. See the MIMS Tariffs – Quick Reference for Health Professionals.  Please note the date of revision.  This document will only be updated periodically, not with every tariff change.

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Manitoba Health, Seniors and Active Living
Epidemiology and Surveillance Unit
4th Floor - 300 Carlton St.
Winnipeg MB  R3B 3M9  CANADA
Phone:  204-788-6396