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

 

Health Care Professionals

 

MHSU-6781

Provider Report Form for Sexually Transmitted and Blood-Borne Infections (STBBI) and STI Treatment

Instructions

Apr 2023

MHSU-4487

STBBI Case Report Form for Point of Care/Rapid Testing

 

Sept 2023

MHSU-0013

Clinical Notification of Reportable Diseases or Conditions

 

Nov 2019

 

Respiratory Diseases

 

 

Coronavirus Disease 2019 (COVID-19) forms have been removed as individual case and contact management is no longer occurring.

 

 

MHSU-7274

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

Emerging Respiratory Pathogens (Public Health Agency of Canada)

Nov 2019

 

Weekly Reporting for Hospitalizations, ICU Admissions, and Deaths with Laboratory-Confirmed Influenza: 2022/2023 Season

Reporting Requirements

Jan 2023

 

Communicable Diseases

 

 

Information can be found here for the collection of Racial/Ethnic Identity, including the collection of First Nations, Metis and Inuit information. A script and training video is also available.

   
 

Documenting Geography for Communicable Disease Investigations in PHIMS

 

April 2019

MHSU-6638

Notification of No Follow-Up Form

Instructions

Nov 2019

MHSU-0002

Communicable Disease Control Investigation Form

Instructions

Oct 2021

MHSU-0003

Monkeypox Investigation Form

Instructions

Aug 2022

MHSU-0003a

Monkeypox Contact Investigation Form

 

Aug 2022

 

Sexually-Transmitted and Blood-Borne Pathogens

 

User Guide for Completion of Surveillance Forms for Reportable Diseases

Overall User Guide

May 2020

MHSU-6784

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

Instructions

May 2020

MHSU-6782

STBBI Contact Investigation Form – Contact Form

Instructions

Nov 2019

MHSU-6780

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

Instructions

Dec 2023

MHSU-2667

Congenital Syphilis Investigation Form

Instructions

Oct 2021

MHSU-4482

HIV Case Report Form for Anonymous Testing

 

Nov 2019

MHSU-2437

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

 

Nov 2019

 

Vaccine Preventable Diseases

 

Nov 2019

MHSU-8733

Vaccine Preventable Disease Investigation Form

Instructions

May 2020

 

Immunization

 

MHSU-2334

Reporting of Adverse Events Following Immunization (AEFI)

User Guide to Completion and Submission of the AEFI Reports

Nov 2019

IIFHCP

Immunization Input Form for Health Care Providers

 

Nov 2019

 

Take Home Naloxone Program and Substance Surveillance

 

 

Enteric, Food and Water-borne Diseases

 

MHSU-3265

VTEC (Shiga toxin-producing) E.coli Food Recall Questionnaire

 

Aug 2023

MHSU-7256

Salmonella Food Recall Questionnaire

 

Oct 2023

MHSU-4372

Hepatitis A Questionnaire

 

Nov 2019

MHSU-5478

Invasive Listeriosis Questionnaire

 

 

Vector-borne and Other Zoonotic Diseases

MHSU-8232

Tick-Borne Disease Clinical Case Report Form

Instructions

May 2020

MHSU-9684

West Nile virus Human Case Investigation Form

Instructions

May 2020

MHSU-7224

Report of Suspected Rabies Exposure

 

Sep 2022

 

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.

 

MHSU-6236

Enteric Outbreak Summary Report

 

Nov 2019

MHSU-6287

Vaccine Preventable and Respiratory Infections Outbreak Summary Report

 

Nov 2019

MHSU-6278

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

 

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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.

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
Epidemiology and Surveillance Unit
4th Floor - 300 Carlton St.
Winnipeg MB  R3B 3M9  CANADA
Email: Information.Analytics@gov.mb.ca