Government of Ontario: Ministry of Community Safety and Correctional Services

Form 1 - Physician Report

Pursuant to the Mandatory Blood Testing Act, 2006 and O. Reg. 449/07

TO BE COMPLETED BY THE REPORTING PHYSICIAN

Note to Physician:
If the applicant submits an application under the Mandatory Blood Testing Act, 2006 the information contained in this form will be disclosed to the medical officer of health and if there is a hearing, the Consent and Capacity Board.

*The respondent is the person whose bodily substances the applicant may have come into contact with.

The applicant must consent to examination, counselling, including counselling respecting prophylaxis or treatment, and base line testing for HIV/AIDS, hepatitis B and hepatitis C. Otherwise, the application shall not proceed.

The application may still proceed if the applicant refuses to consent to prophylaxis or treatment.

You must order base line testing for the applicant in accordance with this form's instructions. You are not required to order base line testing for a listed communicable disease if you have other evidence of the applicant's seropositivity respecting that disease.

The applicant must provide one copy of this form, together with a completed applicant report, to the medical officer of health in the appropriate health unit no more than seven days after he or she came into contact with the bodily substance of the respondent. Otherwise, the application is invalid and shall not proceed under the Mandatory Blood Testing Act, 2006.

Once completed, please give two copies of this physician report to the applicant and retain one copy for your records.

A . Applicant Information
Collection of the information on this form is for the determination of an application under the Mandatory Blood Testing Act, 2006, for an order requiring a respondent to give a blood sample to determine the HIV/AIDS, hepatitis B and/or hepatitis C status of the respondent. The authority for collection and use of this information is the Mandatory Blood Testing Act, 2006. For information about collection practices contact the Corrections and Community Safety Policy Branch, Ministry of Community Safety and Correctional Services at 416 325-7331.

Last Name
First Name
Middle Initial

Address: Unit Number
Street Number
Street Name
City/Town
Province
Postal Code
Home Telephone
Business Telephone
OHIP number (10 digits)
Version; Sex; Male
Female; Age
Date of birth (yyyy/mm/dd)

Family Physician - if different from Reporting Physician
Last Name
First Name
Middle Initial: Unit Number
Street Number
Street Name
City/Town
Province
Postal Code
Office Telephone
Office Fax Number

B. Reporting Physician Information
Physician's Name - Please Print or Use Physician's Stamp
Last name
First name
Middle Initial

Office Address: Unit Number
Street Number
Street Name
City/Town
Province
Postal Code
Office Telephone
Office Fax Number

C. History of Exposure - As reported by the applicant

Date of exposure (yyyy/mm/dd)
Time of exposure: am
pm

Type of exposure the applicant experienced
Percutaneous injury (e.g. needle stick or cut by sharp object)
Bite which breaks the skin
Contact with applicant’s non-intact skin (e.g. cut, chapped or abraded skin)
Contact with applicant’s vagina or anus
Contact with applicant’s mucous membrane (eyes, nose, mouth): eyes
nose
mouth
Other/Specify:

Type of bodily substance with which the applicant had contact
Blood, serum, plasma - please select if known.: blood
serum
plasma
Any biologic fluid/substance visibly contaminated with blood (tears, nasal secretions, sputum, vomitus, urine or faeces) - please select if known.: tears
nasal secretions
sputum
vomitus
urine
faeces
Plueral, pericardial, peritoneal, synovial, amniotic or cerebro-spinal fluid or tissues- please select if known.: plueral
pericardial
peritoneal
synovial
amniotic
cerebro-spinal
Uterine/vaginal secretions or semen: Uterine/vaginal secretions
semen
Saliva: specify:

Description of circumstances surrounding the occurrence as explained by applicant

D. Examinations
Findings of examinations related to the occurrence including assessment of injuries sustained (if any)

E. Immunization History / Serostatus of Applicant

Immunization/Serostatus
Received Hepatitis B vaccine: Yes
Date (yyyy/mm/dd)- if applicable
Serostatus Results - if applicable
No
Unknown

Immunization/serostatus
Known to be a carrier - HBs Ag positive: Yes
Date (yyyy/mm/dd)- if applicable
Serostatus Results - if applicable
No
Unknown

Immunization/serostatus
Known to be a immune - Anti-HBs positive: Yes
Date (yyyy/mm/dd)- if applicable
Serostatus Results - if applicable
No
Unknown

Immunization/serostatus
Known to be HCV positive: Yes
Date (yyyy/mm/dd)- if applicable
Serostatus Results - if applicable
No
Unknown

Immunization/serostatus
Known to be HIV positive: Yes
Date (yyyy/mm/dd)- if applicable
Serostatus Results - if applicable
No
Unknown

F. Base Line Testing - mandatory for application to proceed unless applicant previously known to be positive

Note to Physician:: Applicant's base line testing requisition is to be marked "STAT".
A copy of the applicant's base line testing results must be sent to the applicant's family physician (if known) and the reporting physician named in section B above.

Anti HBc: Yes
Date ordered (yyyy/mm/dd)
Refused by applicant

Hepatitis B surface antigen (HbsAg): Yes
Date ordered (yyyy/mm/dd)
Refused by applicant

Anti HBs: Yes
Date ordered (yyyy/mm/dd)
Refused by applicant

Anti HCV: Yes
Date ordered (yyyy/mm/dd)
Refused by applicant

Antibody to HIV: Yes
Date ordered (yyyy/mm/dd)
Refused by applicant

G. Post-exposure Prophylaxis and Treatment

Hep B Vaccine: Yes
Date commenced (yyyy/mm/dd)
N/A
Refused by applicant

Hep B Immune Globulin (HBIG): Yes
Date commenced (yyyy/mm/dd)
N/A
Refused by applicant

Post-exposure prophylaxis for HIV: Yes
Date commenced (yyyy/mm/dd)
N/A
Refused by applicant

H. Counselling Relevant to the Occurence
The applicant has consented to counselling respecting the occurrence, including post-exposure prophylaxis and treatment.
Yes
No (counselling refused by applicant)

I. Referral for Post-Exposure Follow-up and Care - if applicable
Physician's Name - Please Print or Use Physician's Stamp
Last name
First name
Middle Initial

Office Address: Unit Number
Street Number
Street Name
City/Town
Province
Postal Code
Office Telephone
Office Fax Number

J. Assessment of Reporting Physician

As a physician qualified to make a physician report under the Mandatory Blood Testing Act, 2006 and based on information provided to me by the applicant and after referencing the most recent publication protocols, such as the OHA/OMA Communicable Disease Surveillance Protocols for Ontario Hospitals - Blood-borne Diseases (Revised December 2002), my assessment of the applicant's risk of exposure to HIV/AIDS, Hepatitis B and/or Hepatitis C is:: potentially significant
non-significant
indeterminate

Physician’s name- please print: Last name
First name
Signature
Date (yyyy/mm/dd)