Manitoba Health

Forms

The following surveillance forms have been approved by the Minister for reporting and public health investigation and may be obtained by calling (204) 788-6737 or by clicking on the links below. 

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

• Clinical Notification of Reportable Diseases or Conditions NEW
• Communicable Disease Control Investigation Form
• Enhanced Surveillance E. Coli O157: H7 Questionnaire NEW
  (August 2010)
• HIV/AIDS Case Report
• HIV Case Investigation Form for Nominal & Non-Nominal Positive Cases
• HIV Case Report Form for Anonymous Testing
  (April 2008)
• HIV Case Report Form for Rapid HIV Testing
  (April 2008)
• HIV Contact Notification Form NEW
• Influenza NEW
  • Provincial Reporting Requirements for Severe Outcomes Associated with Laboratory Confirmed Influenza: 2011/2012 Season
  • Weekly Aggregate Reporting of Hospitalizations, ICU Admissions, and Deaths: 2011/2012 Influenza Season
• Invasive Listeriosis Questionnaire NEW
• Investigation Form for Clostridium difficile-Associated Disease (CDAD)
• Investigation Form for Hepatitis B and C Positive Cases
• MIMS: Immunization Input Form for Facilities and Clinics - Revised—March 2010
• MIMS: Immunization Table Listing
• MIMS: Immunization Tariff Codes
• MIMS: Immunization from History Tapes
• MIMS: Regional Health Unit Listings
• MIMS: Native Band Listings
• MIMS: Municipality Listing
• MIMS: Physician Listing Request (alphabetic)
• MIMS: Physician Listing Request (numeric)
• Notification of Sexually Transmitted Disease Form
• Outbreak Report
• Phone Report of Possible Rabies Exposure
• Report of a Vaccine-Associated Adverse Event
  • User Guide to Completion and Submission of the AEFI Reports NEW
• Salmonella Questionnaire - General NEW
• Severe Respiratory Illness (SRI) Case Report Form NEW
• West Nile virus Public Health Human Case Investigation Interim Short Form (2008)
• West Nile virus Public Health Human Case Investigation Long Form (2008)

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Immunization Tariff Codes

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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.

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 (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.

To reach staff and for general enquiries:

Public Health and Primary Health Care Manitoba Health 4th Floor - 300 Carlton St. Winnipeg MB  R3B 3M9  CANADA Phone:  (204) 788-6666