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Division of Communicable disease control

Communicable Disease Control Forms

Infectious Diseases Case Report Forms

(Forms are provided for use by health professionals only)

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

 Disease

 Form Number

Form Title                                                                                                                      (PDFs are available in the CalREDIE Document Repository)
Anthrax (Human) CDC CS338924A
 CDC Anthrax Case Report Form (Known Event/Outbreak)

CDC Anthrax Case Investigation Form
Babesiosis CDPH 8270
 Babesiosis Case Report
Botulism (Food or Wound) CDPH 8547
 Botulism Case Report
Brucellosis CDPH 8607
Brucellosis Case Report
Campylobacteriosis
 CDPH 8621
 Campylobacteriosis Case Report
Chikungunya
 CDPH 8618
 Chikungunya Case Report
Cholera and Other Vibrio Illness

CDPH 8587

CDC OMB 0920-0728

Cholera and Other Vibrio Illness Case Report

CDC Cholera and Other Vibrio Illness Seafood Investigation Report (Section 5 of COVIS, CDC OMB 0920-0728): This form should be used to report seafood investigations associated with Cholera and Vibrio illness.
Coccidioidomycosis CDPH 8280
 Coccidioidomycosis Case Report
Creutzfeldt-Jakob Disease 
 CDPH 9002 
 Creutzfeldt-Jakob Disease (CJD) Case Report
Cyclosporiasis
 CDC OMB 0920-1198
 Cyclosporiasis National Hypothesis Generating Questionnaire
Cysticercosis
 CDPH 8581
 Cysticercosis/Taeniasis Case Report
Dengue and Severe Dengue CDPH 8670
 Dengue and Severe Dengue Case Report
Diphtheria CDPH 8579 
 Diphtheria Case Report
Ehrlichiosis/Anaplasmosis CDPH 8573
 Ehrlichiosis/Anaplasmosis Case Report
Guillian-Barreā€™ Syndrome CDPH 9073
 Guillian-Barreā€™ Syndrome (GBS) Surveillance Case Report
Gonorrhea
 CDPH 9064 (coming soon)
 Gonorrhea Case Investigation Record
Haemophilus influenzae, Invasive Disease PM 401 (PDF) Invasive Haemophilus Influenzae Disease Case Report
Hantavirus Infection
 CDPH 9077 
 Hantavirus Infections Case Report
Hepatitis A
 CDPH 8556 (PDF)
 Hepatitis A Case Report
Hepatitis B, Perinatal

CDPH 8702 (PDF)

CDPH 8505 (PDF)

CDPH 8546 (PDF)

CDPH 8546 sub-form (PDF)

Hepatitis B, Perinatal Case Report

Hepatitis B, In-State Case Transfer Form

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

Perinatal Post-Exposure Prophylaxis (PEP) Errors

Hepatitis B, Acute

 CDPH 8703 B (PDF)
 Acute Hepatitis B Case Report
Hepatitis C, Acute
 CDPH 8703 (PDF)
 Acute Hepatitis C Case Report
Hepatitis C, Perinatal
 CDPH 8704 (PDF)
 Perinatal Hepatitis C Case Report
Hepatitis E
 CDPH 8701 
 Hepatitis E Case Report
Influenza, Severe
 CDPH 9070 (PDF)
 Severe Influenza Case History Form (ICU and Fatal Cases)
Influenza, Novel CDC OMB 0920-0004 (PDF) Novel Influenza Case History Form
Legionellosis
 CDPH 8588 
 Legionellosis Case Report
Leprosy (Hansenā€™s Disease) NHDP Hansenā€™s Disease (Leprosy) Surveillance
Leptospirosis CDPH 8577 
 Leptospirosis Case Report
Listeriosis

CDPH 8296

CDPH 8297 

Listeriosis Case Report

Neonatal Listeriosis Case Report
Lyme Disease CDPH 8470 
 Lyme Disease Case Report
Malaria CDPH 8657
 Malaria Case Report
Measles (Rubeola) CDPH 8345 (PDF) Measles (Rubeola) Case Report-California 
Meningococcal Disease

CDPH 8469 (PDF)

 Meningococcal Disease Case Report
Mumps CDPH 8690 (PDF)
 Mumps Case Report
Pertussis (Whooping Cough)

CDPH 8258 (PDF)

Pertussis Case Report
Plague (Human) CDPH 8549
 Plague (Human) Case Report
Poliovirus CDPH 8421 (PDF) Poliovirus Infection or Poliomyelitis Case Report
Psittacosis CDPH 8583
 Psittacosis Case Report
Q Fever CDPH 8548
 Q Fever Case Report

Rabies, Human

Rabies, Animal

CDPH 8526 

CDPH 102

Human Rabies Case Report

Animal Rabies Case Report

Relapsing Fever

 CDPH 8561 
 Relapsing Fever Case Report
Rocky Mountain Spotted Fever CDPH 8575
 Spotted Fever Rickettsioses Case Report
Respiratory Syncytial Virus (RSV) CDPH 8265 (PDF)
 Respiratory Syncytial Virus (RSV) Death Form (<5 years)

Rubella, (German Measles)

Congenital Syndrome

PM 358 (PDF)

Appendix 17 (PDF)

Rubella (German Measles) Case Report

Congenital Rubella Syndrome Case Report
S. Typhi and S. Paratyphi-Infection
 CDPH 8586
 Typhoid and Paratyphoid Fever Case Report
Salmonellosis
 CDPH 8640
 Salmonellosis Case Report
Shiga Toxin-Producing Escherichia coli (STEC) and/or Hemolytic Uremic Syndrome (HUS)
 CDPH 8555
 Shiga Toxin-Producing Escherichia coli (STEC) and/or Hemolytic Uremic Syndrome (HUS) Case Report
Shigellosis CDPH 8639
 Shigellosis Case Report
Spotted Fever Rickettsioses (Including Rocky Mountain Spotted Fever) CDPH 8575
 Spotted Fever Rickettsioses Case Report

Syphilis

 

CDPH 9049 (PDF)

CDPH 9040 (PDF)

California Congenital Syphilis (CS) Case Investigation and Report

Out of State Syphilis Record Search Request
Taeniasis
 CDPH 8581
 Cysticercosis/Taeniasis Case Report
Tetanus

Appendix 18 (PDF)

Appendix 18 Instructions (PDF)

Tetanus Surveillance Worksheet

Tetanus Surveillance Worksheet Instructions
Trichinosis
 CDPH 8606
 Trichinosis Case Report
Tuberculosis

CDPH 8620 RVCT

 Tuberculosis Form
Tularemia
 CDPH 8559 
 Tularemia Case Report
Typhoid Carrier

CDPH 8563

CDPH 8566

CDPH 8466

Typhoid Carrier Agreement

Typhoid Carrier Case Report

Typhoid Carrier-Register-Semiannual Update
Typhus and Other Non-Spotted Fever Rickettsioses
 CDPH 8580
 Typhus and Other Non-Spotted Fever Rickettsioses Case Report
Varicella (Chickenpox)

CDPH 8299 (PDF)

CDC (CDPH Revised,1.39MB)

CDC (PDF)

CDPH 9056 (Excel)

Varicella (Chickenpox) Hospitalization Case Report

Varicella Death Investigation Worksheet

Varicella Death Investigation Worksheet-Instructions

Varicella Outbreak Report
Vibrio Illness (Non-Cholera)

CDPH 8587

CDC OMB 0920-0728

Cholera and Other Vibrio Illness Case Report

CDC Cholera and Other Vibrio Illness Seafood Investigation Report (Section 5 of COVIS, CDC OMB 0920-0728): This form should be used to report seafood investigations associated with Cholera and Vibrio illness.

Viral Hemorrhagic Fever, Human

Viral Hemorrhagic Fever, Animal

CDPH 8527 

CDPH 8528

Viral Hemorrhagic Fever Case Report

Viral Hemorrhagic Fever (Animal) Case Report
West Nile Virus Infection

CDPH 8687

West Nile Virus Infection Case Report
Yellow Fever
 CDPH 8584 
 Yellow Fever Case Report
Yersiniosis
 CDPH 8622
 Yersiniosis Case Report
Zika
 CDPH 8680
 Zika Case Report

 

Outbreak-Disease Report Forms and Related Documents

(Two or more cases from a common source)

Outbreak

 Form Number

 Form Title

Acute Respiratory Illness Outbreak

(Community and Congregate Settings)

 CDPH 9003 (PDF)

Acute Respiratory Illness Outbreak 

(Community and Congregate Settings)

Foodborne Disease Outbreaks

Foodborne Disease Outbreak Report

 

 

 

CDPH 8567 (PDF,1.77MB)

 

CDPH 8567 Instructions (PDF)

 

 

Contributing Factors (PDF)

 

Case-Control Study (Excel)

 

Cohort Study (Excel)

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 (For calculating odds ratios, 95% confidence intervals, and chi-square p-values)

Food-Specific Attack Rate Table (For calculating risk ratios, 95% confidence intervals, and chi-square p-values)
Varicella (Chickenpox) Outbreak CDPH 9056 (Excel) Varicella (Chickenpox) Outbreak Report Form

Waterborne Disease Outbreaks

CDC NORS-Waterborne Disease Outbreak Form
Instructions CDC 52.12 Instructions (PDF,1.15MB) Instructions for Completing CDC 52.12
Complete Form CDC 52.12 (PDF)

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.
Treated Recreational Water CDC 52.12 (PDF)

Recreational Water-Treated (fillable)

This version of CDC 52.12 should be used to report waterborne disease outbreaks associated with treated recreational water.
Untreated Recreational Water CDC 52.12 (PDF)

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 CDC 52.12 (PDF)

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

 CDC 52.12 (PDF)

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.

 

Other Report and Data Forms


Form

 Form Number

 Form Title
Confidential Morbidity Report (CMR) CDPH 110 A (PDF,1.83MB)
 Confidential Morbidity Report (CMR)

Use this form for reporting all conditions except Tuberculosis and conditions reportable to DMV. Initial report required from provider for any reportable disease.
CDPH 110 B (PDF) Only use this form for reporting Tuberculosis.
CDPH 110 C (PDF,1.78MB)
 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 110 D (PDF)
 Only use this form for reporting COVID-19.
CDPH 8572 (PDF,1.64MB) Confidential Morbidity Report for Animal Patients (CMR)
Use this form for reporting conditions in animal patients.
Interstate Reciprocal Notification of Disease for Reporting Out-of-State Cases CDC 42.1 e (PDF) Interstate Reciprocal Notification of Disease
Request for Data CDPH 9078 (PDF) Request for Infectious Diseases Branch Surveillance Data
STD Data Request CDPH 9046 (PDF) STD Data Request
STD Health Department Follow-Up CDPH 9047 (PDF) STD Health Department Follow-Up

 

Forms are provided for use by health professionals only. If you are having difficulty accessing any of these documents, please contact CDPH
at (916) 558-1784 to request information in an alternate format.ā€‹

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