Case name: ...................................................................................... DOB ......../......../........ Notification ID: ..............................

First name Surname

Typhoid-Paratyphoid Case Report Form

............................................................................... Public Health Unit Outbreak ID: .......................................

Completed by: ...................................................................................... Date sent to NOCS: ......../......../.........
Telephone: ............................................... Fax: ................................................

NOTIFICATION:
Date PHU notified: ......../......../........ Date initial response: ......../......../........
Notifier: .................................................................................................... Organisation: ...........................................................................
Telephone: ........................................ Fax: ...................................... Email: ......................................................................................
Treating Dr: ............................................................................................................................................................................................................
Telephone: ........................................ Fax: ...................................... Email: ......................................................................................

CASE DETAILS: UR No: ....................................................................................

Name: ....................................................................................................................................................................................................................
First name Surname

Date of birth: ......./......../........ Age: .......... Years ......... Months Sex: 

Male 
Female .............................................

Name of parent/carer: ..........................................................................................................................................................................................


Aboriginal  Torres Strait Islander 
Aboriginal & Torres Strait Islander 
Non-Indigenous 
Unknown

English preferred language:  Yes 

No – specify .................................. Ethnicity – specify ...............................................

Permanent address: ..............................................................................................................................................................................................

................................................................................................................................................................... Postcode: .........................................

Home telephone: ..................................... Mobile: .......................................... Email: ......................................................................................

Occupation: ..................................................................................................... Work telephone: ....................................................................
Temporary address in Queensland (if different from permanent address): .....................................................................................................
................................................................................................................................................................... Postcode: .......................................

Telephone: ........................................ Mobile: .................................. Email: ......................................................................................

General Practitioner: Dr ........................................................................................................................................................................................
Address: ..................................................................................................................................................... Postcode: .........................................
Telephone: ........................................ Fax: ................................... Email: ......................................................................................

CLINICAL DETAILS:
Date of onset of symptoms: ......../......../........ Date of first consultation: ......../......../........
What was the first symptom: ..............................................................................................................................................................................
Symptoms:

Nausea  Malaise Diarrhoea  Cough

Fever Headache Rash Constipation
Other – specify: .....................................................................................................................................................................................................
Duration of illness (days): ....................................................................................................................................................................................
Antibiotic: ...................................................... Date commenced ......../......../........ Date completed ......../......../........ (minimum 5 days)

Hospitalised: 
Yes  No  Unknown Hospital: .................................................. Date: ......../......../........ to ......../......../.......

Complications: 
Yes – specify .............................................................................................. 
No 
Unknown

Outcome: 
Survived  Died Date of death: ......../......../........ 
Died of condition 
Unknown

QUEENSLAND HEALTH Surveillance of Notifiable Conditions – Typhoid & Paratyphoid February 2015 1 of 2
Case name: ...................................................................................... DOB ......../......../........ Notification ID: ..............................
First name Surname

LABORATORY:
1st sample: Laboratory: ............................. Collection date: ......../......../........ 
S.Typhi 
S.Paratyphi – serotype ..........................
......../......../........  
nd
2 sample: Laboratory: ............................. Collection date: S.Typhi S.Paratyphi – serotype ..........................
......../......../........  
rd
3 sample: Laboratory: ............................. Collection date: S.Typhi S.Paratyphi – serotype ..........................
Chronic carrier? 
Yes 
No 
Unknown serotype ..................................................

EXPOSURE PERIOD:
Typhoid: Date: ......../......../........ to Date: ......../......../........
(Onset date – 60 days) (Onset date – 3 days)

Paratyphoid: Date: ......../......../........ to Date: ......../......../........

(Onset date – 10 days) (Onset date – 1 day)

TRAVEL HISTORY:
Provide travel history during exposure period (within Australia and overseas)
Country/region visited Arrival date Departure date Comments
1 .................................................................................... ......./......../........ ......../......../........ ...................................................................
2 .................................................................................... ......./......../........ ......../......../........ ...................................................................
3 .................................................................................... ......./......../........ ......../......../........ ...................................................................

CONTACTS:
During this time was there contact with confirmed/suspected case(s) 
Yes 
No 
Unknown
Name / NID: ................................................................. Telephone: .......................... Contact type: ........................................................
Name / NID: ................................................................. Telephone: .......................... Contact type: ......................................................

PLACE ACQUIRED:

Queensland 
Other Australian state/territory – specify ..........................................................................................................

Unknown 
Other country – specify ......................................................................................................................................


NOTIFICATION DECISION:
Confirmed – Typhoid case

Confirmed – Paratyphoid case

INFECTIOUS PERIOD:
Typhoid/Paratyphoid: Date: ......../......../........ to Date: ......../......../........
(Onset date) (Faecal clearance as per Guidelines or 48 hours after completion
of appropriate antibiotic course or resolution of symptoms,
whichever comes last)

Was case in hospital during infectious period? 

Yes 
No 
Unknown Hospital: ................................................................
Period of hospitalisation ......../......../........ to ......../......../........ Ward: .....................................................................
During the infectious period, did the case have a high risk occupation i.e. food handler, carer of patients, carer of children, carer of the
elderly, carer of those unable to maintain personal hygiene:

Educational/residential facility – specify .................................................. Telephone: ........................ Dates attended: .......................

Childcare/kindergarten/preschool – specify ............................................ Telephone: ........................ Dates attended: .......................

Indigenous community – specify ............................................................. Telephone: ........................ Dates attended: .......................

Healthcare facility – specify ...................................................................... Telephone: ........................ Date ......../......../........

Carer – Other – specify ............................................................................. Telephone: ........................ Date ......../......../........
Did the case prepare or handle cooked or ready-to-eat food while infectious? 
Yes 
No 
Unknown
Is the case a food handler? (e.g. commercial catering, food business) 
Yes 
No 
Unknown
Food outlet: ................................................................................................................................ Telephone: ....................................................

Was the case excluded from high risk setting? 

Yes 
No 
Unknown
COMMENTS:

Queensland Health Surveillance of Notifiable Conditions – Typhoid & Paratyphoid February 2015 2 of 2
Case name: ......................................................................
First name
CONTACT MANAGEMENT
If contact is asymptomatic and 'high risk', exclude from high risk duties until 2 negative specimens at least 24 hours apart. If case has not travelled to endemic area, all household
contacts should provide 2 specimens 24 hours apart, but need not be excluded unless 'high risk'.
Contact (household or
travel companion)
............................................
Clearance advised by PHU staff:
......../......../........
............................................
Clearance advised by PHU staff:
......../......../........
............................................
Clearance advised by PHU staff:
......../......../........
............................................
Clearance advised by PHU staff:
......../......../........
............................................
Clearance advised by PHU staff:
......../......../........
............................................
Clearance advised by PHU staff:
......../......../........
* High risk occupation includes food handlers, carers of patients, carers of children, carers of the elderly, those unable to maintain personal hygiene and their carers
Surname
DOB/Age
.........................
.........................
.........................
.........................
.........................
.........................
Queensland Health
DOB ......../......../........ Notification ID: ...........................................................................
(For PHU use only)
Date of first Is contact High risk occupation* Stool samples for Result/comments
exposure symptomatic? If clearance
Yes, give date of
onset
 Yes 
No 
Unknown ............................................. Lab ......../......../........ .................................
Date excluded by PHU staff: Lab ......../......../........ .................................
......../......../........ ......../......../........ ......../......../........
 Yes 
No 
Unknown ............................................. Lab ......../......../........ .................................
Date excluded by PHU staff: Lab ......../......../........ .................................
......../......../........ ......../......../........ ......../......../........ .
 Yes 
No 
Unknown ............................................. Lab ......../......../........ .................................
Date excluded by PHU staff: Lab ......../......../........ .................................
......../......../........ ......../......../........ ......../......../........
 Yes 
No 
Unknown ............................................. Lab ......../......../........ .................................
Date excluded by PHU staff: Lab ......../......../........ .................................
......../......../........ ......../......../........ ......../......../........
 Yes 
No 
Unknown ............................................. Lab ......../......../........ .................................
Date excluded by PHU staff: Lab ......../......../........ .................................
......../......../........ ......../......../........ ......../......../........
 Yes 
No 
Unknown ............................................. Lab ......../......../........ .................................
Date excluded by PHU staff: Lab ......../......../........ .................................
......../......../........
......../......../........ ......../......../........ .
Surveillance of Notifiable Conditions – Typhoid & Paratyphoid February 2015