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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 [""] below Suspected/Confirmed on _______ / _______ / ________ (Date: dd/mm/yyyy)
* Corresponding to monkeypox as specified in Schedule 1 under Cap. 599.
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. Sep 2023)