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 
unless otherwise indicated.
Form Number |
Category / Form Name |
User Guide |
Last Update |
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Respiratory Diseases |
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The collection of Racial, Ethnic and Indigenous Identity information is an important part of the public health response to COVID-19 in Manitoba. As of May 1, 2020, all health-care providers completing the COVID-19 case investigation form have been directed to ask a mandatory question regarding Racial/Ethnic Identity. This is in addition to the collection of First Nations, Metis and Inuit identifiers which began on April 3, 2020. More information can be found here, along with a script and training video. |
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Coronavirus Disease 2019 (COVID-19) Case Investigation Form |
Oct 2021 |
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Abbreviated Coronavirus Disease 2019 (COVID-19) Case Investigation Form |
Dec 2021 |
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Coronavirus Disease 2019 (COVID-19) Contact Investigation Form |
Jan 2021 |
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Coronavirus Disease 2019 (COVID-19) PCH/LTCF Resident Case Investigation Form |
Dec 2021 |
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COVID-19 Case Report Form for COVID-19 Testing |
Nov 2021 |
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Multisystem Inflammatory Syndrome in Children (MIS-C) Clinical Case Form |
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Dec 2020 |
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Severe Acute Respiratory Infection (SARI) and Emerging Respiratory Pathogens – Case Report Form |
Emerging Respiratory Pathogens (Public Health Agency of Canada) |
Nov 2019 |
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Weekly Reporting for Hospitalizations, ICU Admissions, and Deaths with Laboratory-Confirmed Influenza: 2022/2023 Season |
Jan 2023 |
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Communicable Diseases |
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Documenting Geography for Communicable Disease Investigations in PHIMS |
April 2019 |
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Notification of No Follow-Up Form |
Nov 2019 |
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Clinical Notification of Reportable Diseases or Conditions |
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Nov 2019 |
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Communicable Disease Control Investigation Form |
Oct 2021 |
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Monkeypox Investigation Form |
Aug 2022 |
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Monkeypox Contact Investigation Form |
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Aug 2022 |
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Sexually-Transmitted and Blood-Borne Pathogens |
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User Guide for Completion of Surveillance Forms for Reportable Diseases |
May 2020 |
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STI Case Investigation Form For Chlamydia, Gonorrhea, Chancroid and LGV Infections – Case Form |
May 2020 |
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STBBI Contact Investigation Form – Contact Form |
Nov 2019 |
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Provider Report Form for Sexually Transmitted and Blood-Borne Infections (STBBI) and STI Treatment |
Apr 2023 |
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Hepatitis B and C, HIV, and Syphilis Investigation Form – Case Form |
May 2020 |
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Congenital Syphilis Investigation Form |
Oct 2021 |
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HIV Case Report Form for Anonymous Testing |
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Nov 2019 |
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HIV Case Report Form for Rapid HIV Testing |
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Nov 2019 |
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HIV/AIDS Case Report – use for reporting AIDS cases only |
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Nov 2019 |
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Vaccine Preventable Diseases |
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Nov 2019 |
Vaccine Preventable Disease Investigation Form |
May 2020 |
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Immunization |
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Reporting of Adverse Events Following Immunization (AEFI) |
Nov 2019 |
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Immunization Input Form for Health Care Providers |
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Nov 2019 |
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Take Home Naloxone Program and Substance Surveillance |
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Overdose Response Form |
Jan 2022 |
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Enteric, Food and Water-borne Diseases |
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Enhanced Surveillance E. Coli O157: H7 Questionnaire |
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Nov 2019 |
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Salmonella Questionnaire - General |
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April 2023 |
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Hepatitis A Questionnaire |
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Nov 2019 |
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Invasive Listeriosis Questionnaire |
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Vector-borne and Other Zoonotic Diseases |
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Tick-Borne Disease Clinical Case Report Form |
May 2020 |
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West Nile virus Human Case Investigation Form |
May 2020 |
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Report of Suspected Rabies Exposure |
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Sep 2022 |
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Outbreaks |
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Enteric Outbreak Summary Report AND Respiratory/Vaccine Preventable Disease Outbreak Summary Report |
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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. |
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Enteric Outbreak Summary Report |
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Nov 2019 |
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Vaccine Preventable and Respiratory Infections Outbreak Summary Report |
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Nov 2019 |
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Outbreak Summary Report (NOT Enteric or Respiratory/Vaccine Preventable Disease Outbreaks) |
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Outdated Forms No Longer Being Accepted |
Please Use Instead: |
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MHSU-4228 |
Hepatitis B and C Case Investigation Form |
MHSU-6780 |
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MHSU-4486 |
HIV Case Investigation Form for Nominal and Non-Nominal Positive Cases |
MHSU-6780 |
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MHSU-6787 |
Mumps Case Investigation Form |
MHSU-8733 |
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MHSU-7974 |
Syphilis Case Investigation Form |
MHSU-6780 |
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HIV Contact Notification Form |
MHSU-6782 |
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Syphilis Contact Investigation Form |
MHSU-6782 |
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Notification of Sexually-Transmitted Disease Form |
MHSU-6784 |
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Immunization Tariff Codes
In Manitoba, immunization tariff codes serve two important functions:
- To link an immunizing agent provided by a health care provider to an individual's immunization record in the Manitoba Immunization Monitoring System (MIMS).
- 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:
- For MIMS Users - select the Inquire General Table Information from the Operator Primary Menu, then select - Inquire Immunization Table.
- 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). - Contact a MIMS user at the nearest local Public Health office.
- 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.
Manitoba Health |
