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FORM 2
PREVENTION AND CONTROL OF DISEASE ORDINANCE
(Cap. 599)
Notification of Infectious Diseases other than Tuberculosis
Particulars of Infected Person

Name in English: Name in Chinese: Age / Sex: I.D. Card / Passport No.:
Residential address: Telephone No.
(Home) :
(Mobile) :
(Office / school / others):
Name and address of workplace / school:
Job title / Class attended:
Hospital / Clinic sent to (if any): Hospital / A&E No.:

Disease ["tick"] below Suspected/Confirmed on _______ / _______ / ________ (Date: dd/mm/yyyy)

Acute poliomyelitis Haemophilus influenzae type b infection (invasive) Relapsing fever
Amoebic dysentery Hantavirus infection Rubella and congenital rubella syndrome
Anthrax Invasive pneumococcal disease Scarlet fever
Bacillary dysentery Japanese encephalitis Severe Acute Respiratory Syndrome
Botulism Legionnaires' disease Shiga toxin-producing Escherichia coli infection
Chickenpox Leprosy Smallpox
Chikungunya fever Leptospirosis Streptococcus suis infection
Cholera Listeriosis Tetanus
Community-associated methicillin-resistant Staphylococcus aureus infection Malaria Typhoid fever
Coronavirus disease 2019 (COVID-19) Measles Typhus and other rickettsial diseases
Creutzfeldt-Jakob disease Melioidosis Viral haemorrhagic fever
Dengue fever Meningococcal infection (invasive) Viral hepatitis
Diphtheria Middle East Respiratory Syndrome West Nile Virus Infection
Enterovirus 71 infection Monkeypox Whooping cough
Food poisoning Mumps Yellow fever
Number of persons known to be affected: _______
Place and district of consumption
(e.g. “XX Restaurant in Mongkok”):
__________________________________________
__________________________________________
Date of consumption: _________________________
Novel influenza A infection Zika Virus Infection
Paratyphoid fever
Plague
Psittacosis
Q fever
Rabies

Notified under the Prevention and Control of Disease Regulation by

Dr. ______________________________ of ___________________________Hospital / Clinic / Private Practice

(Full Name in BLOCK Letters)

_________________________Ward / Unit / Specialty on ______ / _______ / ________ (Date: dd/mm/yyyy)

Telephone No.: _______________ Fax No.: _______________ (Signature) ___________________

Remarks:

DH 1(s)(Rev. Nov 2022)

9 Nov 2022