Victorian Numbered Regulations Victorian Numbered RegulationsIn Schedule 4 to the Principal Regulations, for Forms 3 and 4 substitute —
"Form 3: For Group D Notification for HIV—Strictly Confidential
1. Identification
Name Code (First
two letters of family name, First two letters of given name)
Date of
birth
Sex
2. Other characteristics
Country of
birth
Indigenous status
If born overseas, year of arrival in Australia
Language other than English spoken at home
Residential postcode
Date of onset
of illness
Current state of person:
If alive—date of most recent contact
If deceased—date of death
3. Notifying doctor
Name
Address
Hospital name (if appropriate)
Phone number
Signature
Date of notification
4. Reason for testing
Exposure risk
(see section 6)
Investigation of clinical symptoms
Screening—
Blood,
organ or semen donor
Insurance
Immigration
Antenatal
Confirmation of HIV
positive status
Other
5. Diagnosis
Date of first diagnosis
of HIV infection
State/Territory of first diagnosis of HIV infection
CD4+
count or viral load at first diagnosis of HIV infection or both
History of HIV
seroconversion illness
Date of HIV seroconversion illness
Has the person had a
previous HIV test
Date of last test
Result of last HIV test
Source of
information on last test, patient, doctor or laboratory
6. Exposure category
Note: More than one exposure category may be notified.
Person was interviewed in regard to exposure:
*Not at all (provide reasons)
*To a certain extent (provide the following details)
*In depth (provide the
following details)
* Delete if inapplicable
Sexual exposure
Note: At least one of the following must be notified.
Sexual
contact only with person of same sex
Sexual contact with both sexes (if female
see section 6a)
Sexual contact only with person of opposite sex (see
section 6a)
Sexual contact with a person from another country (write
country)
No sexual contact
Sexual exposure not known
Vertical exposure
Mother with/at risk of HIV infection (see section 6b)
Blood exposure
Injecting drug use (detail)
Recipient of blood, blood products
or tissue (detail)
Haemophilia/coagulation disorder (detail)
Other exposure
History of tattoos (date/place)
History of ear/body piercing
(date/place)
History of major/minor surgery (date/place)
Exposure other than
those given above (type/date/place)
Exposure could not be established (detail)
6a. Sexual contact
Note: At least one of the following must be answered if MALE
reports sexual contact with person of opposite sex or if FEMALE reports sexual
contact with either same or OPPOSITE sex.
Sex with bisexual male (women only)
Sex with injecting drug user
Sex with person from another country (write
country)
Sex with a person who received blood, blood products or tissue
Sex
with a person with haemophilia/ coagulation disorder
Sex with person with HIV
infection whose exposure is other than those above (specify)
Sex with person
with HIV infection whose exposure could not be established
Heterosexual
contact not further specified
6b. Vertical exposure category
Note: At least one of the following must be answered if
parent/guardian reports vertical exposure from mother to child only.
Mother
with/at risk of HIV infection due to—
Injecting drug use
Recipient of
blood, blood products or tissue
Origin from another country (write country)
Has HIV infection, exposure not specified
Sex with bisexual male
Sex with
injecting drug user
Sex with person who received blood, blood products or
tissue
Sex with person with haemophilia/coagulation disorder
Sex with person
from another country (write country)
Sex with person with HIV infection,
exposure not specified
Other (specify)
7. Donation of blood or other bodily fluid or tissue prior to HIV diagnosis
Note: If this item is applicable, specify type of donation, date and place of donation.
Timing of Notice
Written notification with details of the data elements listed
in items 1 to 7, within 5 days of the initial diagnosis.
__________________
Form 4: For Group D Notification for AIDS—Strictly Confidential
1. Identification
Name Code (First
two letters of family name, First two letters of given name)
Date of birth
Sex
2. Other characteristics
Country of
birth
Indigenous status
Residential postcode
If born overseas, year of arrival
into Australia
Language other than English spoken at home
Current state of
person—
• If person is alive, date of most recent contact
• If person has died, date of death
3. Notifying doctor
Name
Address
Hospital name (if appropriate)
Phone number
Signature
Date of notification
4. Diagnosis
Date of AIDS diagnosis
Has the person previously been diagnosed with AIDS elsewhere? Yes/No/Unknown
• If yes and diagnosis was in another State/Territory, specify State/Territory and date
• If yes and diagnosis was overseas, specify country and date
5. Laboratory tests
Date of first
diagnosis of HIV infection
CD4+ count or viral load at AIDS diagnosis or both
Date of specimen collection for CD4+ count analysis
Note: The CD4+ count and viral load results need to be forwarded as part of your notification when the count and results are available.
6. Anti-retroviral therapy
Has the
person been treated with anti-retroviral therapy?
If yes, specify month/year
when started
7. Diseases indicative of AIDS at diagnosis
Note: At least one of the following must be notified. State
whether definite or presumptive.
Pneumocystis carinii pneumonia
Oesophageal
candidiasis
Kaposi's sarcoma (specify site)
Herpes simplex virus of >1
month duration (specify site)
Cryptococcosis (specify site)
Cryptosporidiosis
(diarrhoea >1 month)
Toxoplasmosis (specify site)
Cytomegalovirus (specify
site)
Atypical Mycobacteriosis (specify type)
Pulmonary tuberculosis
Extrapulmonary tuberculosis
Lymphoma
Non-Hodgkin's lymphoma, primary of
brain/CNS
Non-Hodgkin's lymphoma, other site (specify type)
HIV encephalopathy
(includes AIDS Dementia Complex)
HIV wasting syndrome
Invasive cervical cancer
Recurrent pneumonia
Other (specify)
8. Exposure category
Note: More than one exposure category may be notified.
Person was interviewed in relation to exposure:
*Not at all (provide reasons)
*To a certain extent (provide the following details)
*In depth (provide the
following details)
* Delete if inapplicable
Sexual exposure
Note: At least one of the following must be notified.
Sexual
contact only with person of same sex
Sexual contact with both sexes (if female
see section 8a)
Sexual contact only with person of opposite sex (see
section 8a)
Sexual contact with a person from another country (write
country)
No sexual contact
Sexual exposure not known
Vertical exposure
Mother with/at risk of HIV infection (see section 8b)
Blood exposure
Injecting drug use (detail)
Recipient of blood, blood products
or tissue (detail)
Haemophilia/coagulation disorder (detail)
Other exposure
Exposures other than those above apply (provide details)
Exposure could not be established (detail)
8a. Sexual contact
Note: At least one of the following must be answered if MALE
reports sexual contact with person of opposite sex or if FEMALE reports sexual
contact with either same or OPPOSITE sex.
Sex with bisexual male (women only)
Sex with injecting drug user
Sex with person from another country (write
country)
Sex with a person who received blood, blood products or tissue
Sex
with a person with haemophilia/coagulation disorder
Sex with person with HIV
infection whose exposure is other than those above (specify)
Sex with person
with HIV infection whose exposure could not be established
Heterosexual
contact not further specified
8b. Vertical exposure category
Note: At least one of the following must be answered if
parent/guardian reports vertical exposure from mother to child only.
Mother
with/at risk of HIV infection due to—
Injecting drug use
Recipient of
blood, blood products or tissue
Origin from another country (write country)
Has HIV infection, exposure not specified
Sex with bisexual male
Sex with
injecting drug user
Sex with person who received blood, blood products or
tissue
Sex with person with haemophilia/coagulation disorder
Sex with person
from another country (write country)
Sex with person with HIV infection,
exposure not specified
Other (specify)
Timing of Notice
Written notification with details of the data elements listed
in items 1 to 8b, within 5 days of the initial diagnosis.
__________________".