Australian Capital Territory Numbered Regulations

PUBLIC HEALTH (INFECTIOUS AND NOTIFIABLE DISEASES) REGULATIONS(AMENDMENT) (NO. 27 OF 1992) - REG 7

    (a)     by omitting “Acquired Immune Deficiency Syndrome”; and

    (b)     by inserting after “Dengue”, “HIV (Category 1, 2 or 3)” and “HIV (Category 4—Acquired Immune Deficiency Syndrome)” respectively.

    Form 2     Subregulations 4 (1)
    Australian Capital Territory     ^{and 4B (1) and (2)}

Public Health Act

Public Health (Infectious and Notifiable Diseases) Regulations

Attending Doctor Name	National Number (If known)
Address
	Notes for Attending Doctor Please indicate HIV infection status of the person
Hospital Name (if appropriate)		Diagnosed HIV infection (Category 1, 2, or 3) Complete Part A Only
Signature (Medical Practitioner)     /     /		Diagnosed HIV infection (Category 4 - Acquired Immune Deficiency Syndrome) Complete Parts A and B

A1 Identification of Person with HIV infection			A3 Exposure Category
			Person was interviewed with regard to exposure
Family Name (first 2 letters only)					Not at all (Detail)
Given Name (first 2 letters only)					To a certain extent (Answer questions below)
Date of Birth     /     /					In depth (Answer questions below)
Sex     Male         Female			More than one exposure category may be ticked Sexual Exposure - at least one box should be ticked
Male Transexual         Female Transexual     Postcode of current residence						Sexual contact only with person of same sex Sexual contact with both sexes (if female see A4)
A2 Diagnosis of HIV infection Date of first diagnosis of HIV infection     /     /						Sexual contact only with person of opposite sex (see A4) From a specified country (Pattern - II or other Country 1 )     Country
State/Territory of first diagnosis of HIV infection						No sexual contact Sexual exposure not known
CD + 4 count at first diagnosis of HIV infection			Blood Exposure
Did the person present with a seroconversion illness?		Yes         No				Injecting drugs - Detail
Date of seroconversion illness		/     /				Recipient of blood, blood products or tissue - Detail
						Haemophilia/coagulation disorder - Detail
Has the person had a previous negative antibody test?		Yes         No	Vertical Transmission
Date of last negative antibody test		/     /				Mother with/at risk of HIV infection - (see A5)
Source of last negative test		Patient	Other Exposure
		Doctor				Exposure other than those above applies - Detail
		Laboratory				Exposure could not be established - Detail
A4 Sexual contact with person of opposite sex				A5 Vertical Transmission
Please indicate category of source person				Mother with / at risk of HIV infection due to
					Injecting drug use
	Bisexual male (women only)				Recipient of blood transfusion, blood components or tissue
	Injecting drug user				Origin in Pattern - II Country 1
	Person who received blood transfusion, blood products or tissue				Country
	Person with haemophilia/coagulation disorder				Has HIV infection, exposure not specified
	Person from Pattern - II or other country 1				Sex with bisexual male
	Country				Sex with injecting drug user
	HIV infected person whose exposure is other than those above				Sex with person who received blood transfusion, blood products or tissue
	Specify				Sex with person with haemophilia/coagulation disorder
	HIV infected person, exposure not specified				Sex with person from Pattern - II or other country 1     Country
	Other exposure				Sex with HIV infected person, exposure not specified
	Detail				Other exposure     Detail

B1 Diagnosis of HIV infection (Category 4 - Acquired Immune Deficiency Syndrome 2 )	B5 Diseases indicative of Category 4 Diagnosis     At lease one must be ticked Definitive Prescriptive
Date of Category 4 diagnosis     /     /			Pneumocystis carinii pneumonia
Has the person been previously diagnosed as Category 4 elsewhere?         Yes         No/Unknown			Oesophageal
(1)     If YES and diagnosis was in another State/Territory     Specify			Kaposi's Sacoma Herpes simplex virus > 1 month duration     Site
(2)     If YES and diagnosis was overseas, write country			Cryptococcosis     Site
			Cryptosporidiosis (diarrhoea > 1 month)
B2 Other characteristics of Category 4			Toxoplasmosis     Site
Country of Birth         Australia			Cytomegalovirus     Site
Other specify			Mycobacteriosis     Type
If OTHER, state year of arrival in Australia			Lymphoma     Site     Type
Current Status of Person			HIV encephalopathy
(1)     Person is alive. Date of most recent contact     /     / (2)     Person has died. Date of death     /     /			HIV wasting syndrome

B3 Laboratory Tests for Category 4 Diagnosis

Other specify

Date of first diagnosis of HIV infection     /     /	Footnote 1	Pattern - II countries
CD4 + count at Category 4 Diagnosis CD4 + results to be forwarded when available	The original Pattern - II countries were sub-Saharan Africa and the Caribbean, where transmission is thought to be predominantly heterosexual. This definition should now be expanded to include countries from South East Asia and India.
Date of specimen collection for CD4 + count analysis     /     /	Footnote 2	Case definition for AIDS
B4 Antiviral Therapy	1987 revision of case definition for AIDS for surveillance purposes. MMWR Vol 36 No. 15, 1978
Indicate if the person has been treated with any of the following retroviral agents (If YES, Specify month/year when started)	ACT Health - Office Use Only
19     Zidovudine     19     ddl	Initials of ACT Health Officer
19     ddC     19     Other	Territory Case No.
	Date notification received at Health		Date Forwarded to National Centre
specify	/     /		/     /
			h2560(8/92)

    Form 3     Subregulation 4A (1)
    Australian Capital Territory

Public Health Act

Public Health (Infectious and Notifiable Diseases) Regulations
*Pathologist includes a laboratory assistantand a technical officer employed in a laboratory.

Infection

Referring Doctor Details

The specimen taken from the person whose name and address appear below indicates infection with Method ofidentification (Pleasetick) antigen/antibodydetected microscopy serology culture Species/subtype Specimen/site Comments PatientDetails Surname (first 2letters ONLY for HIV infection) Given name (first 2 lettersONLY for HIV infection) Full name of patient ( do not include for HIV infection) Address (do not include for HIVinfection)

Name Telephone Address Pathology/Laboratory (Write or Stamp) Name Address Telephone

Postcode (include for HIV infection)
Date of Birth	Age		Sex
Date of Collection	Date of Notification