Jadual
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.
280/5/7; PN(PU2)470/II]
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.
280/5/7; PN(PU2)470/11]
DATO' SRI LIOW TIONG LAI
Minister of Health 7