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CONTACTS TO CONTACT FORM  \nCHLAMYDIA, GONORRHEA, CHANCROID, LGV, HEPATITIS B/C, HIV, AND SYPHILIS INFECTIONS)  \n * INVESTIGATION INFORMATION  \n\n| 1. CONTACT TO A CASE OF 􀂆 CHLAMYDIA 􀂆 GONORRHEA 􀂆 LGV 􀂆 CHANCROID 􀂆 HBV 􀂆 HCV 􀂆 HIV 􀂆 SYPHILIS |  |  |\n| --- | --- | --- |\n| 2. INVESTIGATION DISPOSITION | 􀁻 FOLLOW-UP COMPLETE 􀁻 UNABLE TO COMPLETE INTERVIEW 􀁻 PENDING |  |\n| 3. DOES CASE PLAN TO NOTIFY THIS CONTACT HIM/HERSELF? |  | 􀂆 YES 􀂆 NO 􀂆 NOT ASKED |\n| 4. RESPONSIBLE ORGANIZATION | 􀁻 WRHA 􀁻 NRHA 􀁻 PMH 􀁻 SH-SS 􀁻 IERHA 􀁻 FNIHB 􀁻 CSC |  |\n| 5. OTHER ORGANIZATIONS INVOLVED | 􀂆 WRHA 􀂆 NRHA 􀂆 PMH 􀂆 SH-SS 􀂆 IERHA 􀂆 FNIHB 􀂆 CSC 􀂆 DND |  |\n\n *CLIENT IDENTIFICATION subject > client details > personal information  \n\n| 6. LAST NAME |  | 7. FIRST NAME |  | 8. SEX\u003Cbr>􀁻 FEMALE 􀁻 MALE 􀁻 INTERSEX\u003Cbr>􀁻 UNKNOWN |\n| --- | --- | --- | --- | --- |\n| 9. ALTERNATE LAST NAME |  | 10. ALTERNATE FIRST NAME |  | 11. DATE OF BIRTH/APPROX. AGE\u003Cbr>IF DATE USE YYYY-MM-DD |\n| 12. MHSAL REGISTRATION NUMBER\u003Cbr>6 DIGITS |  | 13. HEALTH NUMBER (PHIN)\u003Cbr>9 DIGITS |  | 14. ALTERNATE ID\u003Cbr>SPECIFY TYPE OF ID |\n| 15. ADDRESS AT TIME OF TESTING 􀃎 􀂆 ADDRESS IN FIRST NATION COMMUNITY |  |  |  | 16. CITY/TOWN/VILLAGE |\n| 17. PROVINCE/TERRITORY | 18. POSTAL CODE\u003Cbr>A\\#A \\#A\\# |  | 19. PHONE NUMBER\u003Cbr>\\#\\#\\# - \\#\\#\\# - \\#\\#\\#\\# | MHSU USE ONLY |\n| 20. ALTERNATE ADDRESS/LOCATING INFORMATION |  |  |  |  |\n| 21. PHYSICAL DESCRIPTION IF UNABLE TO IDENTIFY CLIENT |  |  |  |  |\n\nCOMPLETE SECTIONS III AND IV BASED ON INFORMATION PROVIDED BY THE CASE  RISK FACTOR INFORMATION subject > risk factors  \n22. CONTACT KNOWN TO BE PREGNANT? 􀁻 NO 􀁻 UNKNOWN 􀁻 NOT APPLICABLE 􀁻 YES (COMPLETE SECTION VI EDC FROM CONTACT)  \n EXPOSURE DETAILS investigation > exposure summary > maintain transmission event details  \n\n| 23. MODE OF TRANSMISSION (SELECT ALL THAT APPLY)\u003Cbr>􀂆 SEXUAL 􀂆 BLOODBORNE\u003Cbr>􀂆 PERINATAL (IF PERINATAL SKIP TO SECTION V) |  |  |  | 24. *EXPOSURE START DATE\u003Cbr>YYYY-MM-DD 􀂆 ESTIMATED |  |  | 25. EXPOSURE END DATE\u003Cbr>YYYY-MM-DD |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| A. SEXUAL EXPOSURE |  |  | >> transmission event details > transmitter role >> source details > mode of transmission = sexual contact |  |  |  |  |\n| 26. SEXUAL RELATIONSHIP\u003Cbr>(SELECT ONE ONLY) |  | 􀁻 REGULAR PARTNER 􀁻 CASUAL PARTNER\u003Cbr>􀁻 HAS GIVEN GOODS IN EXCHANGE FOR SEX 􀁻 HAS RECEIVED GOODS IN EXCHANGE FOR SEX\u003Cbr>􀁻 DECLINED TO ANSWER |  |  |  |  |  |\n| 27. TYPE OF SEXUAL EXPOSURE (SELECT ALL THAT APPLY) 􀂆 VAGINAL SEX 􀂆 ANAL SEX 􀂆 ORAL SEX |  |  |  |  |  |  |  |\n| 28. FREQUENCY OF SEXUAL CONTACT EVENTS 􀁻 ONCE ONLY 􀁻 2-10 TIMES 􀁻 11+ TIMES 􀁻 UNKNOWN 􀁻 DECLINED |  |  |  |  |  |  |  |\n| B. BLOOD AND PERCUTANEOUS EXPOSURES >> source details > mode of transmission = bloodborne |  |  |  |  |  |  |  |\n| 􀂆 DRUG PARAPHERNALIA SHARING | 􀂆 BLOODMUCOUS MEMBRANES |  | 􀂆 SHARED TATTOO, BODY PIERCING, SCARIFICATION EQUIPMENT |  | 􀂆 HOUSEHOLD (HEPATITIS B ONLY)\u003Cbr>>> exposure location > exposure setting type | 􀂆 OTHER BLOODBORNE EXPOSURES\u003Cbr>SPECIFY |  |\n\n* IDENTIFIES CRITICAL DATA ELEMENT OR SECTION TO BE COMPLETED. IF THIS DATA IS MISSING, THE FORM WILL BE RETURNED. MHSU-6782 (2019-11-27)– STBBI CONTACT INVESTIGATION FORM (FOR CHLAMYDIA, GONORRHEA, CHANCROID, LGV,  \nHEPATITIS B/C, HIV, AND SYPHILIS CONTACTS)  \nMHSAL– SURVEILLANCE UNIT: 4th FLOOR – 300 CARLTON ST. WINNIPEG, MB CONFIDENTIAL WHEN COMPLETED-Page 1 of 3  \n\n| C. EXPOSURE SETTING LOCATION >> exposure summary > maintain transmission event details > exposure location |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| 29. WHERE / HOW DID YOU FIRST MEET THIS CONTACT (SELECT ONE ONLY FOR NEW CONTACTS DURING EXPOSURE PERIOD) |  |  |  |  |\n| 􀂆 BATHHOUSE | 􀂆 BAR/CLUB |  | 􀂆 HOTEL | 􀂆 HOUSE PARTY |\n| 􀂆 FRIENDS/FAMILY | 􀂆 OUTDOORS (PARKS, STREETS, ETC) |  | 􀂆 CORRECTIONAL FACILITY | 􀂆 SHOPPING MALL |\n| 􀂆 WORK/SCHOOL | 􀂆 OTHER COMMUNITIES IN MANITOBA |  | 􀂆 OTHER PROVINCE IN CANADA | 􀂆 OUTSIDE CANADA |\n| 30. INTERNET WEBSITES/APPS\u003Cb","cbCaiaDRp4AocrrA","https://ap.wps.com/l/cbCaiaDRp4AocrrA","pdf",550024,"English","# Investigation Information\n## Client Identification\n## Risk Factor Information\n## Signs and Symptoms\n## Treatment Information\n## Reporter Information","[{\"question\":\"What infections does the STBBI contact investigation form cover?\",\"answer\":\"It covers contact investigations for chlamydia, gonorrhea, chancroid, LGV, hepatitis B/C, HIV, and syphilis.\"},{\"question\":\"Which exposure details are collected for the contact?\",\"answer\":\"It collects mode of transmission and specific exposure details such as sexual relationship and exposure type, bloodborne/percutaneous exposures, exposure start and end dates, and where/how the contact was first met.\"},{\"question\":\"What treatment information is requested in the form?\",\"answer\":\"The form requests prescriber and facility details, whether the contact received epidemiological treatment during the episode, and the listed medication regimens with start dates.\"}]","MHSU-6782 - STBBI Contact Investigation Form - Contact Investigation Information | PDF",1791278173]