Health (Infectious and Notifiable Diseases) Regulations 1966

  • revoked
  • Health (Infectious and Notifiable Diseases) Regulations 1966: revoked, on 4 January 2017, by regulation 16 of the Health (Infectious and Notifiable Diseases) Regulations 2016 (LI 2016/272).

Schedule 1

Form 1 Notice of case of notifiable disease other than Acquired Immune Deficiency Syndrome (AIDS)

Section 74, Health Act 1956

To the Medical Officer of Health at [specify]

and

To [name of local authority]

I hereby notify you that [name of patient or deceased person] is suffering from or is suspected to be suffering from (if person alive) or was affected with (if person deceased) [name of disease].

Particulars relating to patient or deceased person

Address of patient or address where deceased person was residing before death:

Telephone number:

Age:

Sex:

Race:

Occupation or employment:

Place at which employed or previously employed:

Dated at: [place, date]

Signature of medical practitioner:

Schedule 1 form 1: replaced, on 2 January 1986, by regulation 3 of the Health (Infectious and Notifiable Diseases) Regulations 1966, Amendment No 3 (SR 1985/332).

Form 1A Ministry of Health notice of case of notifiable disease, namely, Acquired Immune Deficiency Syndrome

Section 74, Health Act 1956

To the Medical Officer of Health at [specify]

I hereby notify you that a patient under my care is suffering from or is suspected of suffering from (if person alive) or was affected with (if person deceased) Acquired Immune Deficiency Syndrome (AIDS).

Do not identify the patient by name or address

Instead, complete the boxes below with the first two (2) letters of the surname, first initial of given name, sex, and date of birth. If the name begins with “Mac”, “Mc”, “van der” etc, do not include these letters. (For example, a person called James McCallum born on 2 June 1959 would appear as CAJM020659).

1st 2 letters of surname1st initial
of given
name
SexDayMonthYear

Date of diagnosis:

District of usual residence (full address not required):

ETHNIC AFFILIATIONMODE OF INFECTION (more than 1 may be ticked)
European/PakehaHomosexual
MaoriHeterosexual
[detail]
Pacific IslanderReceipt transfusion/blood products
All OthersReceipt coagulation factor
CLINICAL (more than 1 may
be ticked)
Needle sharing between
intravenous drug users
Opportunistic infectionCongenital
[specify type][specify]
Kaposi’s sarcomaOther
[specify]
HIV wasting syndromeNot known
[detail]
HIV encephalopathy
including dementia
Lymphoma
SEROLOGY (Tick one)PRESENT STATUS
HIV antibodyPositiveAlive
serology —NegativeDead
Not doneGone overseas
Moved to: [area health district]
Signature of medical practitioner:Comments:
[Please print name in blockletters next to signature]
Date:
Signature of Medical OfficerComments:
of Health:
Date:

Schedule 1 form 1A: replaced, on 2 November 1989, by regulation 2 of the Health (Infectious and Notifiable Diseases) Regulations 1966, Amendment No 5 (SR 1989/281).

Schedule 1 form 1A: amended, on 1 July 1993, pursuant to section 38(3) of the Health Amendment Act 1993 (1993 No 24).

Form 2 Notice of death from infectious disease

r 6

Section 85, Health Act 1956

To the Medical Officer of Health at [specify]

I hereby notify you that [full name] died of [name of infectious disease] on the [date] at [full address including locality of house, street, and number].

Age of deceased:

Sex:

Name of medical practitioner who signed the death certificate:

Dated at: [place, date]

Funeral Director (or other person having charge of the funeral of the deceased):

Form 3 Certificate of postponement of vaccination

r 22(3)

Regulation 22(3), Health (Infectious and Notifiable Diseases) Regulations 1966

I hereby certify that I am of the opinion that [full name], aged [specify], of [full address], is not now in a fit state of health to be successfully vaccinated against smallpox (or, as the case may be, cannot be safely vaccinated against smallpox by reason of [specify]).

I do therefore postpone the vaccination until [date].*

Dated at: [place, date].

Medical practitioner:

*This date must not be more than 2 months from the date of this certificate.