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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), andthat 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.
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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.
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.
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Anaphylaxis notifying body

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.
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Case Identification

Case - Contact information

Case demographics

Onset and hospitalisation

Approximate time of onset of illness
Approximate time of exposure to suspected cause

Risk history

Clinical comments