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					                                                                                                                                                                         Borang: Health 1 Rev.2005


                                            NOTIFIKASI PENYAKIT BERJANGKIT YANG PERLU DILAPORKAN
                                                         (Seksyen 10, Akta Pencegahan Dan Pengawalan Penyakit Berjangkit 1988)

 A. MAKLUMAT PESAKIT

  1. Nama Penuh (HURUF BESAR):


      Nama Pengiring (Ibu/Bapa/Penjaga):
      (Jika belum mempunyai Kad Pengenalan diri)

  2. No. Kad Pengenalan Diri / Dokumen Perjalanan                                                                                                              Sendiri              Pengiring
                                    (Untuk Bukan Warganegara)

      No. Daftar Hospital / Klinik                                                 Nama Wad:_______________               Tarikh Masuk Wad:                /                /


  3. Kewarganegaraan:                                                                                       4. Jantina:        Lelaki           Perempuan
      Warganegara:
          Ya          Keturunan:                                                                            5. Tarikh Lahir:            /             /

                      Sukuketurunan:
                      (Bagi O/Asli, Pribumi Sabah/Sarawak)                                                  6. Umur:                                Tahun           Bulan           Hari
          Tidak       Negara Asal:
                      Status                                                                                7. Pekerjaan:____________________________________________
                      Kedatangan:           Izin          Tanpa Izin         Penduduk Tetap                      (Jika tidak bekerja, nyatakan status diri)

  8. No. Telefon:                   Rumah             Tel. Bimbit        Pejabat                       -
     (Untuk dihubungi)
  9. Alamat Kediaman                                                                                             10. Alamat Tempat Kerja / Belajar:



 B. DIAGNOSIS PENYAKIT
           1. Acquired Immune Deficiency Syndrome(AIDS)                             16. Kusta (Paucibacillary)                                  31. Tifus - (Scrub)
           2. Batuk Kokol                                                           17. Malaria - (Falciparum)                                  32. Tifoid - (Paratyphoid)
           3. Campak                                                                18. Malaria - (Malariae)                                    33. Tifoid - (Salmonella typhi)
           4. Chancroid                                                             19. Malaria - (Vivax)                                       34. Tuberkulosis - (Pul. - S/Kahak Negatif)
           5. Demam Denggi                                                          20. Malaria - (Lain-lain)                                   35. Tuberkulosis - (Pul. - S/Kahak Positif)
           6. Demam Denggi Berdarah                                                 21. Penyakit Tangan, Kaki dan Mulut                         36. Tuberkulosis - (Lain-lain Pulmonari)
           7. Demam Kuning                                                          22. Plague - (Bubonic)                                      37. Viral Ensefalitis - (Japanese)
           8. Difteria                                                              23. Plague - (Pneumonic)                                    38. Viral Ensefalitis - (Nipah)
           9. Disenteri(Semua Jenis)                                                24. Poliomielitis (Akut)                                    39. Viral Ensefalitis - (Lain-lain)
          10. Ebola                                                                 25. Rabies                                                  40. Viral Hepatitis A (Akut)
          11. Gonorrhoea                                                            26. Relapsing Fever                                         41. Viral Hepatitis B (Akut)
          12. Human Immunodeficiency Virus Infection(HIV)                           27. Sifilis -(Acquired)                                     42. Viral Hepatitis C (Akut)
          13. Keracunan Makanan                                                     28. Sifilis - (Congenital)                                  43. Viral Hepatitis (Lain-lain) - (Akut)
          14. Kolera                                                                29. Tetanus (Neonatorum)
          15. Kusta (Multibacillary)                                                30. Tetanus (Lain-lain)
Selain dari notifikasi bertulis, penyakit berikut perlu dinotifikasi melalui telefon dalam tempoh 24 jam iaitu:- Poliomielitis Akut, Kolera,
Demam Denggi, Diptheria, Keracunan Makanan, Plague, Rabies dan Demam Kuning.
  11. Cara Pengesanan Kes:                                          12. Status Pesakit:                                                         13. Tarikh Onset:
          Kes                 Kontak               FOMEMA *                  Hidup                                                                              -               -

          Ujian Saringan ______________________                              Mati                  -              -

  14. Ujian Makmal:                                                 15. Keputusan Ujian Makmal:                                                 16. Status Diagnosis:

      Nama Ujian: (i)_____________________                                         Positif (_____________________________)                                Sementara (Provisional/Suspected)

      (ii)_______________ (iii)________________                                    Negatif                                                                Disahkan (Confirmed)

      Tarikh Sampel Diambil:                                                       Belum Siap                                                       Tarikh Diagnosis
                  -            -                                                                                                                                -               -

  17. Maklumat Klinikal                                                                                                                     18. Komen:
       Yang Relevan:

 C. MAKLUMAT PEMBERITAHU

  19. Nama Pengamal Perubatan:

  20. Nama Hospital / Klinik dan Alamat:


  21. Tarikh Notifikasi:                     -             -                                                                                                    ………………………………………….
                                                                                                                                                                       Tandatangan
                                                                                                                                                                    Pengamal Perubatan

                                    * Agensi Pemantauan Pemeriksaan Kesihatan Pekerja Asing(FOMEMA)
                                                                                                                                                                            Form: Health 1 Rev.2005


                                            NOTIFICATION OF COMMUNICABLE DISEASES TO BE REPORTED
                                                           (Section 10, Prevention And Control Of Communicable Diseases Act, 1988)

 A. PATIENT INFORMATION

  1. Full Name (CAPITAL LETTER):


      Accompany by(Mother/Father/Guardian):
      (If under age/without Identity Card)

  2. Identity Card Number / Travelling Document:                                                                                                                 Self                Accompany by
                                     (For Non Citizen)

      Hospital/Clinic Reg.Number.                                                   Ward:_______________                Date of Admission:                   /               /


  3. Citizenship:                                                                                          4. Gender:          Male            Female
      Citizen
          Yes        Race/Ethnic:                                                                          5. Date of birth:               /                 /

                     Sub Ethnic:
                     (For Aborigines, Native of Sabah/Sarawak)                                             6. Age:                                   Year               Month        Day
          No         Country of origin:
                     Status of                                                                             7. Occupation:____________________________________________
                     Entry:                     Legal       Illegal        Permanent Resident                   (If unemployed, please state self reference)

  8. Telephone No.:                  Resident            H.phone           Office                     -
    (Contact purposes)
  9. Current Address:                                                                                           10. Address of Employer/School/College/University:



 B. DISEASE DIAGNOSIS
           1. Acute Poliomyelitis                                                   16. Hand, Food and Mouth Disease                           31. Syphilis - Acquired
           2. Acute Viral Hepatitis A                                               17. Human Immunodeficiency Virus Infection                 32. Tetanus Neonatorum
           3. Acute Viral Hepatitis B                                               18. Leprosy (Multibacillary)                               33. Tetanus (Others)
           4. Acute Viral Hepatitis C                                               19. Leprosy (Paucibacillary)                               34. Tuberculosis - PTB Smear Negative
           5. Acute Viral Hepatitis (Others)                                        20. Malaria - Falciparum                                   35. Tuberculosis - PTB Smear Positive
           6. Acquired Immune Deficiency Syndrome(AIDS)                             21. Malaria - Malariae                                     36. Tuberculosis - Extra Pulmonary
           7. Chancroid                                                             22. Malaria - Vivax                                        37. Typhoid - Paratyphoid
           8. Cholera                                                               23. Malaria - Others                                       38. Typhoid - Salmonella typhi
           9. Dengue Fever                                                          24. Measles                                                39. Viral Encephalitis - Japanese
          10. Dengue Haemorrhagic Fever                                             25. Plague - Bubonic                                       40. Viral Encephalitis - Nipah
          11. Diphtheria                                                            26. Plague - Pneumonic                                     41. Viral Encephalitis - (Others)
          12. Dysentery                                                             27. Rabies                                                 42. Whooping Cough
          13. Ebola                                                                 28. Relapsing Fever                                        43. Yellow Fever
          14. Food Poisoning                                                        29. Syphilis - Congenital                                  44.   Other (specify)

          15. Gonorrhoea                                                            30. Typhus - Scrub
Besides by written notification, the following diseases must be notified by telephone within 24 hours, such as:- Acute Poliomyelitis,
Cholera, Dengue, Diptheria, Food Poisoning, Plague, Rabies and Yellow Fever.
  11. Case detection classification:                                  12. Status of patient:                                                   13. Date of Onset:
          Case                Contact                FOMEMA *                  Lived                                                                               -             -

          Screening Test ______________________                                Died               -              -

  14. Laboratory investigation:                                       15. Laboratory investigation result:                                     16. Diagnosis Status:

      Investigation: (i)_____________________                                       Positive (_____________________________)                               Provisional/Suspected

      (ii)_______________ (iii)________________                                     Negative                                                               Confirmed

      Date of specimen taken:                                                       Pending                                                          Date of Diagnosis
                 -               -                                                                                                                                 -             -

  17. Relevant Clinical                                                                                                                  18. Comment:
      Information:

 C. NOTIFIER

  19. Name of Medical Practisioner:

  20. Name and address of Hospital/Clinic:


  21. Date of Notification:                      -           -                                                                                                     ………………………………………….
                                                                                                                                                                           Signature of
                                                                                                                                                                        Medical Practisioner

                                     * Foreign Workers Medical Examination Monitoring Agency(FOMEMA)
                                                                                                                                                                         Borang: Health 1 Rev. 2001
                                                                                                                                                                         No. Siri:
                                     NOTIFIKASI PENYAKIT BERJANGKIT YANG PERLU DILAPORKAN
                                                       (Seksyen 10, Akta Pencegahan Dan Pengawalan Penyakit Berjangkit 1988)

A. MAKLUMAT PESAKIT

    1. Nama Penuh (HURUF BESAR):



    Nama Pengiring (Ibu/Bapa/Penjaga):
    (Jika belum mempunyai Kad Pengenalan diri)

    2. No. Kad Pengenalan Diri / Dokumen Perjalanan
                                                (Untuk Bukan Warganegara)
                                                                                          Sendiri       Pengiring

    No. Daftar Hospital / Klinik                                                          Nama Wad:_______________         Tarikh Masuk Wad:                /            /


    3. Kewarganegaraan:                                                                                 4. Jantina:        Lelaki          Perempuan
       Warganegara
          Ya        Keturunan:                                                                          5. Tarikh Lahir:               /         /
                    Sukuketurunan:
                    (Bagi O/Asli, Pribumi Sabah/Sarawak)                                                6. Umur:                             Tahun          Bulan            Hari
                    Negara Asal:
          Tidak                                                                                         7. Pekerjaan:____________________________________________
                    Status Kedatangan:          Izin          Tanpa Izin      Penduduk Tetap               (Jika tidak bekerja, nyatakan status diri)


    8. No. Talefon:                Rumah        Tel. Bimbit         Pejabat                     -
       (Untuk dihubungi)

    9. Alamat Kediaman                                                                                  10. Alamat Tempat Kerja / Belajar:




B. DIAGNOSIS PENYAKIT
            1. Acute Poliomyelitis                                     16..Gonorrhoea                                                31. Syphilis - Acquired
            2. Acute Flaccid Paralysis                                 17. Hand, Food and Mouth Disease                              32. Tetanus Neonatorum
            3. Acute Viral Hepatitis A                                 18. HIV                                                       33. Tetanus (Others)
            4. Acute Viral Hepatitis B                                 19. Leprosy (Paucibacillary)                                  34. Typhus - Scrub
            5. Acute Viral Hepatitis C                                 20. Leprosy (Multibacillary)                                  35. Tuberculosis - PTB Smear Positive
            6. Acute Viral Hepatitis (Others)                          21. Malaria - Vivax    - Vivax                                36. Tuberculosis - PTB Smear Negative
            7. AIDS                                                    22. Malaria - Falciparum                                      37. Tuberculosis - Extra Pulmonary
            8. Chancroid                                               23. Malaria - Malariae                                        38. Typhoid - Salmonella typhi
            9. Cholera                                                 24. Malaria - Others                                          39. Typhoid - Paratyphoid
          10. Dengue Fever                                             25. Measles                                                   40. Viral Encephalitis - Japanese
          11. Dengue Haemorrhagic Fever                                26. Plague - Bubonic                                          41. Viral Encephalitis - Nipah
          12. Diphtheria                                               27. Plague - Pneumonic                                        42. Viral Encephalitis - (Others)
          13. Dysentery                                                28. Rabies                                                    43. Whooping Cough
          14. Ebola                                                    29. Relapsing Fever                                           44. Yellow Fever
          15. Food Poisoning                                           30. Syphilis - Congenital
Selain dari notifikasi bertulis, penyakit berikut perlu dinotifikasi melalui telefon iaitu:- Poliomielitis(Akut), Kolera, Demam Denggi, Difteria,
Keracunan Makanan, Plague, Rabies dan Demam Kuning.
    11. Cara Pengesanan Kes:                                               12. Status Pesakit:                                             13. Tarikh Onset:
          Kes              Kontak        FOMEMA                                   Hidup                                                              -          -

          Ujian Saringan ______________________                                   Mati              -       -

    14. Ujian Makmal:                                                      15. Keputusan Ujian Makmal:                                     16. Status Diagnosis:

       Nama Ujian: (i)_____________________                                       Positif (_________________)                                   Sementara (Provisional/Suspected)

       (ii)________________ (iii)__________________                               Negatfi                                                       Disahkan (Confirmed)

       Tarikh Sampel Diambil:                                                     Belum Siap                                                 Tarikh Diagnosis
                -          -                                                                                                                         -          -

    17. Maklumat Klinikal                                                                                                      18. Komen:
         Yang Relevan:

C. MAKLUMAT PEMBERITAHU

    19. Nama Pengamal Perubatan:

    20. Nama Hospital / Klinik dan Alamat:


    21. Tarikh Notifikasi:                  -             -                                                                                              ………………………………………….
                                                                                                                                                             Tandatangan
                                                                                                                                                          Pengamal Perubatan

				
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