Surveillance Forms

The following surveillance forms have been approved by the Minister of Health for reporting and public health investigation and may be ordered through MDA, 204-945-3000, or downloaded by clicking on the links below.

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

Form Number

Form Name

Reference

Last Update

MHSU-0013

Clinical Notification of Reportable Diseases or Conditions

 

MHSU-0002

Communicable Disease Control Investigation Form

 

 

Vaccine Preventable Diseases

 

MHSU-6867

Mumps Case Investigation Form

 

 

Sexually-Transmitted and Blood-Borne Pathogens

MHSU-4228

Hepatitis B and C Case Investigation Form

 

MHSU-2437

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

 

MHSU-4486

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

 

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-4426

HIV Contact Notification Form

See MHSU-6782

Deprecated

MHSU-7974

Syphilis Case Investigation Form

 

MHSU-7392

Syphilis Contact Investigation Form

See MHSU-6782

Deprecated

MHSU-0003

Notification of Sexually-Transmitted Disease Form

See MHSU-6784

Deprecated

MHSU-6782

Notification of Sexually-Transmitted and Blood-Borne Infections – Contact Form

User Guide

2017-08-30

MHSU-6784

Notification of Sexually-Transmitted Infections – Case Form

User Guide

2017-08-30

 

Respiratory Diseases

 

MHSU-7274

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

Case Definitions (Public Health Agency of Canada)

 

Influenza – Weekly Reporting Template for Hospitalizations, ICU Admissions, and Deaths with Laboratory-Confirmed Influenza: 2017/2018 Season

Reporting Requirements for Severe Outcomes Associated with Laboratory Confirmed Influenza: 2017/2018 Season

 

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

 

MHSU-9684

West Nile virus Human Case Investigation Form

 

MHSU-7224

Report of Suspected Rabies Exposure

 

2016-10-01

 

Immunization

 

MHSU-2234

Reporting of Adverse Events Following Immunization (AEFI)

User Guide to Completion and Submission of the AEFI Reports

MI-050 MS Word

MIMS: Immunization from History Tapes

 

IMFHC

MIMS: Immunization Input Form for Facilities and Clinics

 

2010-03-01

MI-014 MS Word

MIMS: Immunization Table Listing 

 

MI-022 MS Word

MIMS: Municipality Listing

 

MI-012 MS Word

MIMS: Native Band Listings

 

MI-046 MS Word

MIMS: Physician Listing Request (alphabetic)

 

MI-048 MS Word

MIMS: Physician Listing Request (numeric)

 

MI-010 MS Word

MIMS: Regional Health Unit Listings

 

 

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)

 

 

Emerging Pathogens

 

MHSU-9452

Zika Virus

 

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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, Healthy Living and Seniors.

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