Physician Report
15. A Physician Report shall include, at a minimum, (a) the name, office address, office telephone number and office facsimile number of the reporting physician; (b) personal information respecting the applicant, including the applicant’s full name, full address, telephone number, OHIP number, sex, age and date of birth; (c) the name, office address and office telephone number of the applicant’s family physician, if different from the reporting physician; (d) a description of the occurrence as reported to the reporting physician by the applicant, including the date and time of the occurrence; (e) a statement regarding the type of exposure the applicant experienced and the type of bodily fluid with which the applicant had contact; (f) the reporting physician’s findings of examinations related to the occurrence, including an assessment of any injuries sustained by the applicant; (g) the applicant’s immunization history and serostatus for the prescribed communicable diseases, if known; (h) a description of all base line testing for the prescribed communicable diseases recommended by the reporting physician, including a statement regarding whether the applicant consented or refused to comply with these recommendations; (i) a description of all post-exposure prophylaxis and treatment recommended by the reporting physician, including a statement regarding whether the applicant consented or refused to comply with these recommendations; (j) a statement regarding whether the applicant was counselled respecting the occurrence, including a statement regarding whether the applicant refused counselling; (k) the name, office address, office telephone number and office facsimile number of the physician to whom the reporting physician referred the applicant for post-exposure follow up and care, if applicable; (l) the reporting physician’s assessment of the applicant’s risk of exposure to the prescribed communicable diseases as potentially significant, non-significant or indeterminate; (m) a statement that the reporting physician is qualified to complete a Physician Report under section 22.1 of the Act; (n) the dated signature of the reporting physician; and (o) the following statements: (i) “If the applicant submits an application to the medical officer of health under section 22.1 of the Health Protection and Promotion Act (HPPA), (A) information contained in this form will be disclosed to the medical officer of health and to such other persons the medical officer of health considers necessary for the purpose of the application, and (B) information contained in section “C” (History of Exposure) of this form may be disclosed to the respondent (source)* for the purpose of the application. * The respondent is the person whose bodily substances the applicant may have come into contact with.” (ii) “The applicant must consent to examination, counselling, including counselling respecting prophylaxis or treatment, and base line testing for HIV/AIDS, Hepatitis B and Hepatitis C. Otherwise, the application is invalid and may not be considered by the medical officer of health under section 22.1 of the HPPA. Thus you must order base line testing for the applicant in accordance with this form’s instructions.” (iii) “While the applicant must consent to counselling respecting prophylaxis or treatment, if the applicant refuses to consent to prophylaxis or treatment, his or her application may still be considered by the medical officer of health.” (iv) “Once completed, please give two copies of this Physician Report to the applicant and retain one copy for your records.” (v) “The applicant must provide one copy of this form, together with a completed Applicant Report, to the medical officer of health no more than seven days after he or she came into contact with the bodily substance of the respondent. Otherwise, the application is invalid and may not be considered by the medical officer of health under section 22.1 of the HPPA.” (vi) “Applicant’s base line testing requisition is to be marked “STAT”. A copy of the applicant’s base line testing results must also be sent to the applicant’s physician named in section “B” above.” O. Reg. 166/03, s. 15.