New Zealand Legislation: Regulations

TO THE MEDICAL OFFICER OF HEALTH at 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 is alive) or was affected with (if person is 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 this day of 19 Signature of Medical Practitioner.

TO THE MEDICAL OFFICER OF HEALTH at 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 surname 1st initial of given name Sex Day Month Year DATE OF DIAGNOSIS DISTRICT OF USUAL RESIDENCE —/—/— (full address not required)

ETHNIC AFFILIATION European/Pakeha Maori Pacific Islander All Others MODE OF INFECTION (more than one may be ticked) Homosexual Heterosexual (detail) Receipt transfusion/blood products Receipt coagulation factor Needle sharing between intravenous drug users Congenital (specify) Other (specify) Not known (detail) CLINICAL (more than one may be ticked) Opportunistic infection (specify type) Kaposi's sarcoma HIV wasting syndrome HIV encephalopathy including dementia Lymphoma SEROLOGY (Tick one) HIV antibody serology— Positive Negative Not done PRESENT STATUS Alive Dead Gone overseas Moved to: (area health district) Signature of Medical Practitioner (Please print name in block letters next to signature) Comments: Date: —/—/— Signature of Medical Officer of Health Comments: Date: —/—/—

To the Medical Officer of Health at ............................ 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 .......... this ......... day of ..................... 19 ...... Funeral Director (or other person having charge of the funeral of the deceased).

I hereby certify that I am of the opinion that [Full name], aged ......., 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 .................................................. ). I do therefore postpone the vaccination until the ....... day of ................ 19......*. Dated at ............... this ........ day of .......................... 19..... Medical Practitioner. * This date must not be more than two months from the date of this certificate.