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[接上页] "Please arrange for examination of contacts to be done by the Government Chest Service." Further Remarks: FORM 2 QUARANTINE AND PREVENTION OF DISEASE ORDINANCE (Cap 141) Notification of Infectious Diseases other than Tuberculosis Particulars of Infected Person Name in English: Name in Chinese: Age/Sex: I.D. Card/ Passport No.: Address: Telephone Number: Place of Work/School Attended: Telephone Number: Hospital(s) attended: Hospital/A & E Number:Disease (3) below Suspected/Confirmed on _______/_________/_______. Acute Poliomyelitis Legionnaires' Disease Rubella Amoebic Dysentery Leprosy Scarlet Fever Bacillary Dysentery Malaria Severe Acute Respiratory Syndrome Chickenpox Measles Tetanus Cholera Meningococcal Infections Typhoid Fever Dengue Fever Mumps Typhus Diphtheria Paratyphoid Fever Viral Hepatitis Food Poisoning Plague Whooping Cough Influenza A (H5) Rabies Yellow Fever Japanese encephalitis Relapsing Fever Notified under the Prevention of the Spread of Infectious Diseases Regulations by Dr. _____________________________________ on _________/_____________/_________ (Full Name in BLOCK Letters) (Date) Telephone Number: ____________________ _________________________________________ (Signature) Remarks: (L.N. 81 of 1994; L.N. 347 of 1998; L.N. 80 of 2003; L.N. 15 of 2004; L.N. 138 of 2004) |