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Communicable Disease Control Forms

The Center for Infectious Diseases, Division of Communicable Disease Control, provides these forms for use by health professionals only.

See Reportable Diseases and Conditions for information about specific diseases and conditions that are mandated by state laws and regulations to be reported by healthcare providers and laboratories to local health officers.

Forms are in Adobe PDF format unless otherwise noted.

  • Infectious Diseases Case Report Forms
  • Outbreak - Disease Outbreak Report Forms and Related Documents
  • Other Report Forms
  • AIDS/HIV Forms
    •

    Infectious Diseases Case Report Forms

    Note: Reporting is mandated for all diseases on the list unless otherwise indicated.

    Disease

    Form Number

    Form Title

    Anthrax (Human)

    CDPH 8578 (7/07)

    Anthrax (Human) Case Report

    Botulism
    (Foodborne or Wound)

    CDPH 8547 (7/12)

    Botulism Case Report

    Brucellosis

    CDPH 8607 (4/11)

    Brucellosis Case Report

    Cholera and Other Vibrio Illness

    CDPH 8587 (1/13)

    CDC 52.79  (Sect. IV, 8/07)

     

    Cholera and Other Vibrio Illness Case Report

    CDC Cholera and Other Vibrio Illness Seafood Investigation Report (Section IV of COVIS, CDC 52.79): This form should be used to report seafood investigations associated with Cholera and Vibrio illness.

    Creutzfeldt-Jakob Disease (CJD) and Transmissible Spongiform Encephalopathy (TSE)

    CDPH 9002  (2/12)

    Creutzfeldt-Jakob Disease (CJD) and Transmissible Spongiform Encephalopathy (TSE) Case Report

    Background Information and Guidelines (Letter 1/5/2009 to Local Health Officers and Local Communicable Disease Controllers from CDPH Infectious Diseases Branch)

    Cysticercosis

    CDPH 8581 (7/12)

    Cysticercosis/Taeniasis Case Report

    Dengue (Dengue Fever, Dengue Hemorrhagic Fever, and Dengue Shock Syndrome)

    CDPH 8670 (1/13)

    Dengue Case Report

    Diphtheria

    CDPH 8579 (12/10)

    Diphtheria Case Report

    Ehrlichiosis/Anaplasmosis

    CDPH 8573 (5/12)

    Ehrlichiosis/Anaplasmosis Case Report

    E. coli O157, Other STEC, Shiga Toxin Positive Feces, and/or HUS 

    CDPH 8555 (4/11)

    E. coli O157, Other STEC, Shiga Toxin Positive Feces, and/or HUS Case Report  


    Guillain-Barre' Syndrome (GBS)
    CDPH 9073 (9/10) CDPH 9073 (Word)

    Guillain-Barre' Syndrome (GBS) Surveillance Case Report Form (see GBS Surveillance Project) 09/27/2010

    Gonorrhea

    CDPH 9064  (6/10)

    Gonorrhea Case Investigation Record

    This form is posted for informational purposes only.  Pre-printed forms are available for completion from the local STD programs or the State STD Control Branch (www.std.ca.gov).

    Haemophilus influenzae, Invasive Disease

    PM 401 (5/08)

    Invasive Haemophilus Influenzae Disease Case Report

    Hantavirus

    CDPH 9077  (11/11)

    Hantavirus Infections Case Report

    Hepatitis A

     

    CDPH 8556 (01/12)

    Hepatitis A Case Report

    Hepatitis B, Perinatal

     

    CDPH 8702 (8/08)

    CDPH 8546 (9/10)
     

    CDPH 8546 sub-form (9/10)

    Hepatitis B, Perinatal Case Report

    California Perinatal Hepatitis B Prevention Program Confidential HBsAg+ Case/Household Management Report

    Perinatal Post-Exposure Prophylaxis (PEP) Errors

    Hepatitis B, Acute

    Or

    Hepatits C, Acute

     

    CDPH 8703 (05/13)

    Acute Hepatitis B or C Case Report

    Influenza, Severe 

    CDPH 9070 (PDF)  (1/13)

     

    Guidance Document

    Severe Influenza Case History Form (ICU and Fatal Cases Age 0-64 Years)

     

    Guidance Document on Reporting of Influenza for the 2012-13 Season

    Influenza, Novel

    CDPH 8658  (1/12)

    Novel Influenza Case History Form

    Legionellosis

    CDPH 8588 (8/12)

    Legionellosis Case Report

    Leprosy (Hansen's Disease)

    DHNDP (8/10)

    Hansen's Disease Surveillance (formerly Leprosy Surveillance, CDC 52.18)

    Leptospirosis

    CDPH 8577 (3/12)

    Leptospirosis Case Report

    Listeriosis

    CDPH 8296 (4/11)

    Listeriosis Case Report

    Lyme Disease

    CDPH 8470 (5/12)

    Lyme Disease Case Report

    Malaria

    CDPH 8657 (4/11)

    Malaria Case Report

    Measles (Rubeola)

     

    CDPH 8345 (8/08)

    Measles (Rubeola) Case Report-California
    (also see Rubella (German Measles) in this list)

    Meningococcal Infections

    CDPH 8469 (4/13)
    Meningococcal Contact Follow-Up Sheet

    Meningococcal Disease Case Report 

    Mumps

    CDPH 8690 (05/12)

    Mumps Case Report

    Pertussis (Whooping Cough) 

    CDPH 8258 (5/13)

     

    Pertussis Case Report

    Pertussis Death Worksheet (CDC form) 

    Plague (Human)

    CDPH 8549 (7/11)

    Plague (Human) Case Report

    Poliovirus

    CDPH 8421 (12/10)

    Poliovirus Infection or Poliomyelitis Case Report

    Psittacosis

    CDPH 8583 (11/11)

    Psittacosis Case Report

    Q Fever

    CDPH 8548 (2/12)

    Q Fever Case Report

    Rabies, Human

    Rabies, Animal

    CDPH 8526 (4/11)

    CDPH 102   (10/11) 

    Human Rabies Case Report

    Animal Rabies Case Report

    Relapsing Fever

    CDPH 8561  (6/11) 

    Relapsing Fever Case Report

    Reye Syndrome

    CDC 55.8 (PDF) (8/03)

    CDC Reye Syndrome Case Investigation Report

    Note: Reporting is not mandated.

    Rocky Mountain Spotted Fever

    CDPH 8575 (2/13)

    Spotted Fever Rickettsioses Case Report

    Rubella (German Measles)

    Rubella, Congenital Syndrome

    PM 358 (8/10)


    CDC 71.17 (2/09)

    Rubella (German Measles) Case Report
    (Also see Measles on this list)

    Congenital Rubella Syndrome Case Report

    Salmonellosis

    CDPH 8640 (8/11)

    Salmonellosis Case Report

    Spotted Fever Rickettsioses (Including Rocky Mountain Spotted Fever)

    CDPH 8575 (2/13)

    Spotted Fever Rickettsioses Case Report

    Staphylococcus aureus, Severe (Community-Associated)

    CDPH 9061  (4/13)

     

    Severe Staphylococcus Aureus Infection (Community-Associated) Case Report 

     

    Syphilis

    CDPH 9063  (6/10)

    California Syphilis Interview Record

    This form is posted for informational purposes only.  Pre-printed forms are available for completion from the local STD programs or the State STD Control Branch (www.std.ca.gov).

    Taeniasis

    CDPH 8581 (7/12)

    Cysticercosis/Taeniasis Case Report

    Tetanus

    Appendix 18 (2/09)

    Appendix 18 Instructions


    Questionnaire

    Tetanus Surveillance Worksheet

    Instructions for Completing the Tetanus Surveillance Worksheet

    Supplemental Injecting Drug Use Questionnaire

    Toxic Shock Syndrome
    (Non-Streptococcal)

    CDPH 8599 (5/13)

    Toxic Shock Syndrome (Non-Streptococcal) Case Report

    Trichinosis

    CDPH 8606 (4/11)

    Trichinosis Case Report

    Tuberculosis

    CDPH 8620 A RVCT (12/09)

    CDPH 8620 B RVCT FU-1 (12/09)

    CDPH 8620 C RVCT FU-2 (12/09)

    CDPH 8635 A and B ARPE (9/07)

    For all Tuberculosis Forms, see: Tuberculosis Reporting Forms and Instructions 

    Tularemia

    CDPH 8559 (4/11)

    Tularemia Case Report

    Typhoid Carrier

    CDPH 8563 (7/07) English

    DHS 8563 (SP) (5/99) Spanish-Espanol

    CDPH 8566 (7/11)

    CDPH 8466 (7/07)

    Typhoid Carrier Agreement

    Acuerdo Para Las Personas Portadoras De La Fiebre Tifoidea

    Typhoid Carrier Case Report

    Typhoid Carrier Register-Semiannual Update

    Typhoid and Paratyphoid Fever

    CDPH 8586 (1/12)  

    Typhoid and Paratyphoid Fever Case Report

    Typhus and Other Non-Spotted Fever Rickettsioses 

    CDPH 8580 (8/11)

    Typhus and Other Non-Spotted Fever Rickettsioses Case Report 

    Varicella (Chickenpox)

     

    CDPH 8299 (03/13)

    CDC (CDPH Revised)

    CDC (5/98)

    CDPH 9056 (03/13)

    Varicella (Chickenpox) Hospitalization Case Report

    Varicella Death Investigation Worksheet

    Varicella Death Investigation Worksheet - Instructions

    Varicella Outbreak Report

    Vibrio Illness (Non-Cholera)

    CDPH 8587 (1/13)

    CDC 52.79 (Sect. IV, 8/07)

     

    Cholera and Other Vibrio Illness Case Report

    CDC Cholera and Other Vibrio Illness Seafood Investigation Report (Section IV of COVIS, CDC 52.79): This form should be used to report seafood investigations associated with Cholera and Vibrio illness.

     

    West Nile Virus

    CDPH 8687 (06/12)

     

    West Nile Virus (WNV) Infection Case Report

     

    Yellow Fever

    CDPH 8584 (11/11)

    Yellow Fever Case Report

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    Outbreak - Disease Report Forms and Related Documents

    (Two or more cases from a common source)

    Outbreak

    Form Number

    Form Title

    Acute Febrile Respiratory Illness Outbreak

    (Community and Congregate Settings)

    CDPH 9003 (3/12)

    Acute Febrile Respiratory Illness Outbreak


    (Community and Congregate Settings)

    Foodborne Disease Outbreaks 

      

        Foodborne Disease
        Outbreak Report

       

        
      
        Instructions



     



        Contributing Factors
        

        Case-Control Study



       

       Cohort Study 

     

     

     

     

    CDPH 8567  (2/13)


    CDPH 8567-Fillable (2/13) 

     

    CDPH 8567-Instructions (1/13) 

     



     

    Contributing Factors  (1/12)       


    Excel (1/12)                            
     

     


     Excel (1/12)

     

     

     

    Foodborne Disease Outbreak Report
    California modification of CDC NORS 52.13

    Foodborne Disease Outbreak Report
    California modification of CDC NORS 52.13


    Guidelines for Completing the Foodborne Disease Outbreak Report CDPH 8567.

    Adapted from NORS 52.13 Guidance Document for NORS Users reporting foodborne, person-to-person, and animal contact.


    NORS Guidance for Contributing Factors.


    Case-Control Study Table


    Table for calculating odds ratios, 95% confidence intervals, and chi-square p-values

    Food-Specific Attack Rate Table

    Table for calculating risk ratios, 95% confidence intervals, and chi-square p-values 

    Preliminary Report of Communicable Disease Outbreak

    CDPH 9060  (5/09)

    Preliminary Report of Communicable Disease Outbreak

    Varicella (Chickenpox) Outbreak

    CDPH 9056 (03/13)

    Varicella (Chickenpox) Outbreak Report Form

    Waterborne Disease Outbreaks

          Instructions

          Complete Form            
      





         
          Treated Recreational Water 




        
          Untreated Recreational Water




        
          Water Intended for Drinking 




         
          Water Not Intended for Drinking
          or Water of Unknown Intent

     

    CDC 52.12 Instructions (1/09)

    CDC 52.12     (3/08)







    CDC 52.12 (3/08)





    CDC 52.12 (3/08)





    CDC 52.12 (3/08)





    CDC 52.12 (3/08)

    CDC NORS - Waterborne Disease Outbreak Form

    Instructions for Completing CDC 52.12

    Complete Form (read only, do not use for reporting)

    The complete CDC 52.12 contains sections for 4 categories of water and is posted here for reference only. Please choose the appropriate form below based on the type of water associated with the outbreak being reported.

    Recreational Water - Treated (fillable)

    This version of CDC 52.12 should be used to report waterborne disease outbreaks associated with treated recreational water.

    Recreational Water - Untreated (fillable)

    This version of CDC 52.12 should be used to report waterborne disease outbreaks associated with untreated recreational water.

    Water Intended for Drinking (Drinking Water)(fillable)

    This version of CDC 52.12 should be used to report waterborne disease outbreaks associated with water intended for drinking.

    Water Not Intended for Drinking or Water of Unknown Intent (fillable)

    This version of CDC 52.12 should be used to report waterborne disease outbreaks associated with water not intended for drinking (excluding recreational water) or water of unknown intent.

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    Other Report Forms

    Form:

    Form Number

    Form Title

    Confidential Morbidity Report (CMR)

     

     

     

     

     

     

     

     

     

     

     (10/11)
    CDPH 110 A Use this form for reporting all conditions except Tuberculosis and conditions reportable to DMV.

    CDPH 110 B Only use this form for reporting Tuberculosis.

    CDPH 110 C Use this form for reporting lapses of consciousness or control, Alzheimer's disease or other conditions which may impair the ability to operate a motor vehicle safely (pursuant to H&S 103900).

    CDPH 8572 (10/11) Use this form for reporting conditions in animal patients.

    Confidential Morbidity Report (CMR) 10/3/2011 
    (initial report required from provider for any reportable disease)

    Report form last updated 5/26/2011, Title 17 list of reportable conditions last updated 10/3/2011

     

     

     

     

     

     

     

    Confidential Morbidity Report for Animal Patients (CMR)

    Other Reportable Diseases or Disease of Unusual Occurrence (for any diseases or outbreaks)

    CDPH 8554 (7/07)

    Other Outbreak; Other Reportable Disease or Disease of Unusual Occurrence

    Interstate Reciprocal Notification of Disease for Reporting Out-of-State Cases

    CDC 42.1 e (PDF) (12/02)

    Interstate Reciprocal Notification of Disease

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    Last modified on: 5/10/2013 12:40 PM