Registered medical practitioner notification form template

Health Protection (Notification) Regulations 2010: notification to the proper officer of the local authority
Registered Medical Practitioner reporting the disease
Name
Address
Post code
Contact number
Date of notification
Notifiable disease
Disease, infection or contamination
Date of onset of symptoms
Date of diagnosis
Date of death (if patient died)
Index case details
First name
Surname
Gender (M/F)
DOB
Ethnicity
NHS number
Home address
Post code
Current residence if not home address
Post code
Contact number
Occupation (if relevant)
Work/education address (if relevant)
Post code
Contact number
Overseas travel, if relevant (destinations & dates)

Please send completed forms to: Avon, Gloucestershire & Wiltshire HPT: Public Health England South West, 2

Rivergate, Temple Quay, Bristol, BS1 6EH. E-mail: phe.swhpt@nhs.net Tel: 0300 3038162 (option 1, then option 2)

For urgent notification & advice, please contact Health Protection Team on: 0344 257 8195 List of Notifiable Diseases overleaf.

For guidance on whether the infection is likely to be urgent, see Health Protection Legislation (England) Guidance 2010 table 1 (page 25-27) – available at: http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digital assets/@dh/@en/@ps/documents/digitalasset/dh_114589.pdf