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Anaphylaxis Notification

This form is used for the statutorily required notification of anaphylaxis presentations by Victorian anaphylaxis reporting bodies to the Victorian Department of Health & Human Services, as required by the Public Health and Wellbeing Act 2009. Commonwealth and State privacy legislation does not negate the responsibility to notify, nor to provide the information requested on this form.

The form should take 3-5 minutes to complete.

Please ensure that the case has been informed of the following: •that you are providing this information to the department (as required by law), and•that the department may contact them for further information about their anaphylactic reaction to inform public health action and reduce the risk to others with allergies.
Anaphylaxis has no universally accepted definition, but has been defined by Safercare Victoria as a severe, potentially life-threatening, systemic hypersensitivity reaction, characterised by: •rapid onset of life-threatening airway, breathing, or circulatory problems, and•(usually, but not always) skin and mucosal changes Note: Vomiting and abdominal pain are symptoms of anaphylaxis to insect venom and systemically administered allergens.

Fields marked with * are required

I have reasonable grounds to believe that the person who presented for medical treatment had anaphylaxis *

Suspected cause of the anaphylaxis

Select the most likely suspected cause of the anaphylaxis *

Please also notify this event to the TGA - consult our website for more information.

Please also notify this event to SAEFVIC / AEFI-CAN - consult our website for more information.

Product name

Batch number (if known)

Drug name

Drug type

Food consumed

Name of food premises (and address, if known)

Food consumed *

Product brand name

Food consumed

Specify

Specify other venom source

Vaccine name

Vaccine type

Specify other source

Specify

If you suspect multiple sources of anaphylaxis, please indicate the most likely source above and provide any other suspected sources in the Clinical Comments section of this form.

Anaphylaxis Notifying Body

Please provide the details of the notifying body (hospital) and the details of the diagnosing clinician.
If you are not the diagnosing clinician, please also indicate your name and position within the hospital.

Fields marked with * are required

Anaphylaxis notifying body

Select the hospital that is notifying this anaphylaxis event *

Diagnosing clinician name *

Contact number *

Name and job title of the person completing this notification form (if different to the diagnosing clinician)

Contact number

Email address

Case Details

Timely public health action will be greatly assisted by you providing full patient details, including contact information for the case, along with a clear history of the onset and diagnosis.

Fields marked with * are required

Case Identification

First (given) names(s) *

Last (family) name *

Birth date (dd/mm/yyyy) *

Sex *

Specify sex

Residential street address

Building / Postal details

City / Suburb / Town

State / Territory

Postcode *

Medicare or other healthcare identifier

Case - Contact information

Home telephone

Mobile telephone

Email address

Name of parent, guardian or next of kin (if applicable)

Case demographics

Alive/deceased

Date of death

Is the case of Aboriginal or Torres Strait Islander origin *

Country of birth *

Year first arrived in Australia

Does the case require an interpreter

Language

Onset and hospitalisation

Date of onset of illness *

Approximate time of onset of illness

24 Hour

Minute

Date of exposure to / consumption of suspected cause

Approximate time of exposure to suspected cause

24 Hour

Minute

Date of presentation for treatment of anaphylaxis

Hospital where the case presented
(only complete this field if different to the Notifying Body)

Was the case admitted to hospital

Date admitted

Was the case admitted to the ICU

Prior to arriving at hospital, did the case receive adrenaline treatment

Prior to arriving at hospital, did one or more symptoms resolve

Risk history

Was the case (or responsible adult) carrying an adrenaline auto-injector (e.g. EpiPen or EpiPenJr) when this anaphylaxis event happened

Was the adrenaline auto-injector used to manage the symptoms

The case (or responsible adult) was not carrying an adrenaline auto-injector because

Specify

Is this the case's first medically diagnosed anaphylactic reaction

Did the case have a medically diagnosed allergy to food prior to this anaphylaxis event *

What food is the case allergic to

Clinical comments

Please describe events leading up to hospital presentation, and any other relevant information