Surveillance Forms
The following surveillance forms have been approved by the Minister of Health for reporting and public health investigation and may be downloaded by clicking on the links below.
Note: All documents on this page are in Adobe Acrobat format 
unless otherwise indicated.
Form Number |
Category / Form Name |
User Guide |
Last Update |
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Health Care Professionals |
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Provider Report Form for Sexually Transmitted and Blood-Borne Infections (STBBI) and STI Treatment |
Oct 2024 |
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STBBI Case Report Form for Point of Care/Rapid Testing |
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Sept 2023 |
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Clinical Notification of Reportable Diseases or Conditions |
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Nov 2019 |
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Oct 2024 |
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Respiratory Diseases |
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Coronavirus Disease 2019 (COVID-19) forms have been removed as individual case and contact management is no longer occurring. |
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Severe Acute Respiratory Infection (SARI) and Emerging Respiratory Pathogens – Case Report Form |
Emerging Respiratory Pathogens (Public Health Agency of Canada) |
Nov 2019 |
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Weekly Reporting for Hospitalizations, ICU Admissions, and Deaths with Laboratory-Confirmed Influenza: 2022/2023 Season |
Jan 2023 |
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Communicable Diseases |
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Information can be found here for the collection of Racial/Ethnic Identity, including the collection of First Nations, Metis and Inuit information. A script and training video is also available. |
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Documenting Geography for Communicable Disease Investigations in PHIMS |
April 2019 |
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Notification of No Follow-Up Form |
Nov 2019 |
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Communicable Disease Control Investigation Form |
Oct 2021 |
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Mpox Investigation Form |
March 2024 |
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Mpox Contact Investigation Form |
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March 2024 |
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Sexually-Transmitted and Blood-Borne Pathogens |
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User Guide for Completion of Surveillance Forms for Reportable Diseases |
May 2020 |
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STI Case Investigation Form For Chlamydia, Gonorrhea, Chancroid and LGV Infections |
Oct 2024 |
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STBBI Contact Investigation Form – Contact Form |
Nov 2019 |
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Hepatitis B and C, HIV, and Syphilis Investigation Form – Case Form |
Dec 2023 |
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Congenital Syphilis Investigation Form |
Oct 2021 |
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HIV Case Report Form for Anonymous Testing |
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Nov 2019 |
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HIV/AIDS Case Report – use for reporting AIDS cases only |
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Nov 2019 |
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Vaccine Preventable Diseases |
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Nov 2019 |
Vaccine Preventable Disease Investigation Form |
May 2020 |
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Immunization |
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Reporting of Adverse Events Following Immunization (AEFI) |
Nov 2019 |
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Immunization Input Form for Health Care Providers |
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Nov 2019 |
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Take Home Naloxone Program and Substance Surveillance |
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Enteric, Food and Water-borne Diseases |
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Shiga toxin-producing E.coli (STEC) Food Recall Questionnaire |
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May 2024 |
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Salmonella Food Recall Questionnaire |
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Oct 2023 |
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Hepatitis A Questionnaire |
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Nov 2019 |
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Invasive Listeriosis Questionnaire |
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Vector-borne and Other Zoonotic Diseases |
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Tick-Borne Disease Clinical Case Report Form |
May 2020 |
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West Nile virus Human Case Investigation Form |
May 2020 |
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Report of Suspected Rabies Exposure |
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Jun 2024 |
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Outbreaks |
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Enteric Outbreak Summary Report AND Respiratory/Vaccine Preventable Disease Outbreak Summary Report |
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For non-CNPHI Users: Please contact the local public health CNPHI writer, or download the forms and report directly to Epidemiology & Surveillance, Public Health, Manitoba Health. |
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Enteric Outbreak Summary Report |
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Nov 2019 |
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Vaccine Preventable and Respiratory Infections Outbreak Summary Report |
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Nov 2019 |
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Outbreak Summary Report (NOT Enteric or Respiratory/Vaccine Preventable Disease Outbreaks) |
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Immunization Tariff Codes
In Manitoba, immunization tariff codes serve two important functions:
- To link an immunizing agent provided by a health care provider to an individual's immunization record in the Manitoba Immunization Monitoring System (MIMS).
- To remunerate physicians for immunizations provided via the physician billing system of the Insured Benefits Branch of Manitoba Health.
For a list of all current and cancelled tariff codes in MIMS, four options are available as follows:
- For MIMS Users - select the Inquire General Table Information from the Operator Primary Menu, then select - Inquire Immunization Table.
- For a hard copy - complete the MIMS: Immunization Table Listing form
(to ensure any updates are received, hard copies should be replaced on a regular basis). - Contact a MIMS user at the nearest local Public Health office.
- See the MIMS Tariffs – Quick Reference for Health Professionals. Please note the date of revision. This document will only be updated periodically, not with every tariff change.
Manitoba Health |
