Record of File ♦ Responsible Health Unit Date ♦ Investigator’s Name Investigator’s Signature Investigator’s Initials Designation Investigation Start Date PHI PHN Other Assignment Date PHI PHN Other Call Log Details Date Start Time Type of Call Call To/From Outcome (contact made, v/m, text, email, no answer, etc.) Investigator’s initials Call 1 Outgoing Incoming Call 2 Outgoing Incoming Call 3 Outgoing Incoming Call 4 Outgoing Incoming Call 5 Outgoing Incoming Call 6 Outgoing Incoming Date letter sent: Case Details ♦ Aetiologic Agent Giardia lamblia/ intestinalis/ duodenalis Subtype Further Differentiation ♦ Classification Confirmed Probable Does Not Meet Definition ♦ Classification Date ♦ Outbreak Case Classification Confirmed Probable Does Not Meet Definition ♦ Outbreak Classification Date ♦ Disposition Complete Closed- Duplicate-Do Not Use Entered In Error Lost to Follow Up Does Not Meet Definition Untraceable ♦ Disposition Date ♦ Status Closed ♦ Status Date Open (re-opened) ♦ Status Date Closed ♦ Status Date ♦ Priority High Medium Low (At health unit’s discretion)
- 25 days - 3 days Onset Medical Risk Factors Response Details iPHIS character limit: 50 Yes No Unknown Not asked Immunocompromised (specify) (e.g., by medication or by disease such as cancer, diabetes, etc.) Other (specify) (e.g., use of antacid, surgery, etc.) Unknown → For iPHIS data entry – check Yes for Unknown if all other Medical Risk Factors are No or Unknown. Hospitalization & Treatment Mandatory in iPHIS only if admitted to hospital Did you go to an emergency room? Yes No If yes, name of hospital: Date(s): ♦ Were you admitted to hospital as a result of your illness (not including stay in the emergency room)? Yes No Don’t recall If yes, name of hospital: ♦ Date of admission: Date of discharge: Unknown discharge date → For iPHIS data entry – if the case is hospitalized enter information under Interventions. Were you prescribed antibiotics or medication for your illness? Yes No Don’t recall If yes, medication: Start date: End date: Route of administration: Dosage: Did you take medication? Yes No Don’t recall Treatment information can be entered in iPHIS under Cases > Case > Rx/Treatments > Treatment as per current iPHIS User Guide counter
Behavioural Social Risk Factors in the 3-25 days prior to onset of illness Zoonotic Response Details (e.g., Brand name, purchase/consumption location, product details, date of exposure) iPHIS character limit: 50. Yes No Unknown Not asked Contact with animals, e.g., pets, farm animals or (petting) zoo Other Modes of Transmission Anal-oral contact Close contact with case Poor hand hygiene Other (specify) for all modes of transmission Unknown → For iPHIS data entry – check Yes for Unknown if all other Behavioural Risk Factors are No or Unknown. ♦ Create Exposures Identify Exposures to be entered in iPHIS. → For iPHIS data entry – record details of exposure(s) in iPHIS Case Exposure Form as required. Premises Referral Has a food premise(s) been identified as a possible source? Yes No If yes, refer premises to the Food Safety Program and create an exposure as appropriate. High Risk Occupation/High Risk Environment Are you/ your child in a high risk occupation or high risk environment (including paid and unpaid/volunteer position)? Yes No Child care/kindergarten staff or attendees Food handler Health care provider Other (specify) Occupation: Name of Child care/Kindergarten/Employer
Child care/Kindergarten/Employer Contact Information (name, phone number, etc.) Address High Risk Occupation/High Risk Environment Are you/ your child still experiencing diarrhea? Yes No Last day case attended child care/kindergarten/work: Exclusion required from child care/kindergarten/work? Yes No Case/Parent/Guardian advised that public health unit will contact child care/ kindergarten/work? Yes No Could we have your permission to release your/ your child’s diagnosis to child care/kindergarten/work? Yes No Refer to the current Infectious Diseases Protocol, Giardiasis chapter, Appendix A, Management of Cases section for exclusion pertaining to day care staff and attendees, food handlers, and health care providers. → For iPHIS data entry – if the case is excluded from work or child care/kindergarten enter information under Interventions. Symptomatic Contact Information Are you aware of anyone who experienced similar symptoms before, during, or after you (or your child) became ill? This includes those in your family, household, child care or kindergarten class, sexual partner(s), friends or coworkers. Yes No N/A Contact 1 Name Relation to case Contact information (phone, address, email) Notes Recommend contact seek medical attention/testing? Yes No N/A Contact 2