Peraturan-Peraturan Pencegahan dan Pengawalan Penyakit Berjangkit (Borang Notis) (Pindaan) 2011

Jadual 2 dengan jadual yang berikut:

2

"JADUAL

(Peraturan 2)

Bo rang

(Peraturan 2)

AKTA PENCEGAHAN DAN PENGAWALAN PENYAKIT BERIANGKIT 1988

PERATURAN-PERATURAN PENCEGAHAN DAN PENGAWALAN PENVAIOT BERIANGKIT (BORANG NOTIS)(PINDAAN) 2011

PonIng Notts. Rev/2010

No. SIC

BORANG NOTIFIICASI PENYAKIT BERIANGKIT

Pekin W. Akio rencegaban Dan rangarrolan P avatar Penang 511988)

A. MAKLUMAT HUHN

Nama Penh (HURUF BESAR):

Nama Pengiring (Ibu/Bapa/Penjag

(Oa belum memputiyal End Pengenalan

):

did)

1

No. )(ad Pengenalan Din / Dokumen

(Unwk

No. Daftar Hospital / Klinik

Perja/anan

Bukan Warganegara)

7 1 /

1

Sendiri

[Pengiring 1

Nama Wad:

Tankh Masuk Wad:1

IIIIII1

1

I/

1 1 1 1

3. Kewarganegaraan:

Warganegara:

1

Ya

Ketuntnan:

Sukuketurunan:

(Baal 0/Ask Pribumi

Tidal.

Negara Asa):

Status

Kedatangan:

rantina:

Tarlkh Lahir

Umur

Pekerjaan:

Nam Sok 1

ILelaki 1

fPerempuan

/

nTahun

Hari 1111111 1 111

III/

1 1111 1111 11

1Bu1an

Sabah/Sannvak)

1 1 1 111 11 11

I kin 1

ITanpa Inn 7Penduduk Tetap bekerja, nyatakan status din)

No.

Alamat

Tele( n:

(Untul c chimbungi

Kediaman nRumah

LITel.Bimbit

Pei bat

10. Alamat Temp t K rja

Belalan l:DFAUNOSISPENYAKIT

U

Poliomy litis

Viral Hepati is A

Viral Hepatitis13

Viral Hepatitis C

5. Viral Hepatitis - Lain-lain 1

6. AIDS

1

7. Chat-mu-old

I a. Cholera

9. Dengue Fever

/0. Dengue Haernorrhasic Fever

II. Diphtheria

Dysentery

Ebola

Food Poisoning

Gonorrhoea

C

Ha d. F od and Mouth Disease

HIV la. Influenza

Leprosy (P711rIbaCilialy )

Lep osy (Multibaciliwy )

121. Lep ospirosis

Mal ria • Visas

Malaria • Faktparum

Mal ria • Malarioe

Mal ria • Lain-lain

Measles

Pla ue

Rabies

Rel psing Fever

30. Syp Ills • Congenital

=31. Svuhllis - ACOquired

32. Tetanus Neonatorum

Tetanus - Lain-lain

Typhus-Scrub

135. Tuberkulosis - PIT Smear Positive

Tuberkulosis - PT8SMear Negative

Tuberkulosis - Extra Pala:WO'

MC Typhoid • Salmonella iphi

Typhoid - Paratyphoid

Viral Encephalitis-Japanese

141. Viral Encephalitis - Nipah

42. Viral Encephalitis - Lain-lain

143. Whooping Cough / Pertussis 44 Yellow Fever 1 45 wir her

•

•

=

1

•

1

1

•

•

•

1

IM

IN

=

•

IIIII

•

•

1 I

1

I=

•

•

•

•

I.

Ell

•

•

1

•

•

=

•

I kthitkPi011

Instills, Pe

Dol(,

Ytmnwnan Afakanan, u 4bnaldunatan : .

ton dalam titilife4'4,stir-PoI1OIIM tlsAlPit, IEaJePAIFDem es clan Denies

11. Cara Pengevnan Kea:

Kes 1

Ilcontak fPOMEMA

. On Saringan

12. States Pesakit:

MI litcluP piaci

11 Tarikh Onset

III-1111ml

11

14. Lilian 00 1113ml1111am k

(1)

15. Keputusan Illian 7

Positif

H

NegaDI

1

Beta

Malanal:

(

1

is.srarus D4[110.5151

Sementara (Provisional/Suspected)

Disahkan (Confirmed)

Diagnosis 111-11111111

I.

Tarilch

(PO sup

Tarlih Sampel ()iambi!:

111111 1111

17. Ma klumat Klinikal

Yang Ftelevatl:

10. '<omen:

C. MAKLUMATR

B

Nana Pengental Perubatan:

Nana Hospital / Milk clan Alamat:

21. Tarikh Pemberltahuan:

1 111111111111111111111111

Tandatangan

Pengamal Perubatan

1 1 1 1 1 1 1 1 1 3

Dibuat 1 Jun 2011

[K.K.

DATO' SRI LIOW TIONG LAI

Men ten Kesihatan 4

PREVENTION AND CONTROL OF INFECTIOUS DISEASES ACT 1988

PREVENTION AND CONTROL OF INFECTIOUS DISEASES (NOTICE FORM)

(AMENDMENT) REGULATIONS 2011

IN exercise of the powers conferred by section 31 of the Prevention and Control of

Infectious Diseases Act 1988 [Act 342], the Minister makes the following regulations:

Citation

These regulations may be cited as the Prevention and Control of Infectious

Diseases (Notice Form) (Amendment) Regulations 2011.

Amendment of regulation 2

The Prevention and Control of Infectious Diseases (Notice Form) Regulations 1993

[P.U. (A) 328/1993] is amended in regulation 2 by substituting Schedule 2 with the following Schedule:

5

"SCHEDULE

(Regulation 2)

Form

(Regulation 2)

PREVENTION AND CONTROL OF INFECTIOUS DISEASES ACE 1988

PREVENTION AND CONTROL OF INFECTIOUS DISEASES (NOTICE FORM) (AMENDMENT) REGULATIONS MA gammon Fem.Rev/2mo

Se M ma

NOTIFICATION FORM OF COMMUNICABLE DISEASES

(Section 10, Prevention And Control Of Communicable Diseases Act, 1988)

A.PATIENT INFORMATION

I. Full Name (CAPITAL LETTER):

Accompany by (Mother/Father/Guardian):

Wunder age/without Identity Card)

Identity Card Number / Travelling Document:

(For Non

Hospital/Clinic RegNumber.

Citizen)

1 1 1 1 1 1

/

Self

Accompany y

Ward:

Date of Admission:

1

1

/11111

Citizenship:

Citizen 1 1 es

Race/Ethnic:

Sub Ethnic:

(For Aborigines, Native

_o

Country of origin:

Status of

Entry:

Gender:

Date of birth:

Age:

Occupation:

(If unemployed,

TIMale 1/1

fPemale

/I

Day 1 1111111

1 1 1

1111

17Year

OMonth ofSaboh/Sarawak)

WJ

1 1 7Legalnlilegal 1

/Permanent Resident please state self reference)

B. Telephone Na:

(C nta t purposes)

9. Current Address:

Resident

H.p one

Office 1 1

I ol/College/Univer ity:

10. Address of Empl yer/Sch

B. DISEASE DIAGNOSIS

CI 1. Poromyelids 1 1

2. Viral Hepatitis A

Fever

In 1 18,

119.

Ha d, F od nd Mouth Disease

HIV

Influenza

Leprosy ( Foos/bacillary )

Lep osy ( Multffiacillary )

Leptospirosis

Malaria - Vivax

Ma/ Ma . FolcIparum

Malaria - Malariae

Malaria 'Others

Me ales

Pia ue

Rabies

Re psing Fever

30. Syphilis-Congenital

I-131.

132.

1 133.

134.

I 35.

Syphilis . Accquir d

Tetanus Neonatorum

Tetanus-Others

Typhus-Scrub

Tuberkulosis • PTH Smear Positive

Tuberkulosis - P773 Smear Negative

Tuberkulosis • Extra Pulmonary

38. Typhoid • Salmonella typhi

Typhoid • Paratyphoid

Viral Encephalitis 'Japanese

41. Viral Encephalitis - Nipah

Viral Encephalitis-Others

43. Whooping Cough / Pertussis

Yellow Fever 45 cohavi090 specify '

3. Viral Hepatitis 8

4. Viral Hepatitis C

7

5. Viral Hepatitis-Others

•

6. AIDS

=36.

1

7. Chancroid

•

137.

I. Cholera

•

=

1

9. Dengue Fever

•

139.

140.

Dengue Haemorrhagic

Diphtheria

•

=

lc 12. Dysentery n 13. Ebola

•

142.

•

=

14. Food Poisoning

•

1 144

15. Gonorrhoea

•

=

Besides by written notification. the following diseases must be notified by tel

' Mthln24 hours, such as Acute Poliomyelitis,

Cholera, Dengue, Diptberia, Food Poisoning, Plague, Rabies and Yellow Fever, .

II. Case detection

Ill

IC.Mad

1 OMEMA

12. Status of patient

Live/Allve

Died

13. Date of Onset

-

1 1

.5e 1 11 1 1 1

1

riScreening Test

14. Laboratory Invegagmion:

InveMMation: (I)

15. Laboratory

P Mt'

Negative

„dm, investigation result

( )

16. Diagnosis

IConIlnned tare of 11

[-1Provlsional/Suspected

Status:

agaosis 11-11111111

IIII n 0.1

NO

Date of specimen taken:

1 1

1 1 1

17. Relevant Clinical

Information:

II. Comment:

C. NOTIFIER

Name of Medical Practitioner

Name and address of Hospital/Clinic:

21. Date of Notification:

1

1

1

1

Signature of

Medical Practitioner 1 1 1 1

I'

1

1 6

Made 1 June 2011

[K.K.

DATO' SRI LIOW TIONG LAI

Minister of Health 7