|
Anthrax (Human) |
CDPH 8578 (7/07) |
Anthrax (Human) Case Report |
|
Avian Influenza (Human) |
CDPH Form (8/07) |
Suspect Avian Influenza Case Report
For more forms and instructions, see Avian Influenza Forms and Guidelines |
|
Botulism
(Foodborne or Wound) |
CDPH 8547 (7/07) |
Botulism Case Report |
|
Brucellosis |
CDPH 8558 (7/07) |
Case Report: Brucellosis; Q Fever; Tularemia |
|
Cholera |
CDC 52.79 (8/07) |
Cholera and Other Vibrio Illness Surveillance Report |
|
Dengue |
CDPH 8670 (7/07) |
Dengue Fever Case Report |
|
Diphtheria |
CDPH 8579 (5/07) |
Diphtheria Case Report |
|
Escherichia coli O157:H7 |
CDPH 8555 (2/08) |
STEC/HUS Case Report |
|
Gonorrhea |
CDPH 9064 (7/08) |
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 (5/07) |
Invasive Haemophilus Influenzae Disease Case Report |
|
Hemolytic Uremic Syndrome (HUS) |
CDPH 8555 (2/08)
CDPH 8609 (7/07) |
STEC/HUS Case Report
Hemolytic Uremic Syndrome (HUS) Case Alert |
|
Hepatitis A |
CDPH 8556 (3/08) |
Hepatitis A Case Report |
|
Hepatitis B, Perinatal |
CDPH 8702 (8/08)
CDPH 8546 (1/08) |
Hepatitis B, Perinatal Case Report
California Perinatal Hepatitis B Prevention Program Confidential HBsAg+ Case/Household Management Report |
|
Hepatitis B or C |
CDPH 8703 (10/08) |
Acute Hepatitis B or C Case Report |
|
Kawasaki Syndrome |
CDPH 8468 (7/07) |
Kawasaki Syndrome Case Report |
|
Legionellosis |
CDC 52.56 (2/03) |
Legionellosis Case Report |
|
Leprosy (Hansen's Disease) |
DHNDP (3/96) |
Hansen's Disease Surveillance (formerly Leprosy Surveillance, CDC 52.18) |
|
Leptospirosis |
CDPH 8577 (7/07) |
Leptospirosis Case Report |
|
Listeriosis |
CDPH 8296 (7/07) |
Listeriosis Case Report |
|
Lyme Disease |
CDPH 8470 (7/07) |
Lyme Disease Case Report |
|
Malaria |
CDPH 8657 (7/07) |
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 (2/08) |
Meningococcal Disease Case Report |
|
Mumps |
CDPH 8690 (8/08) |
Mumps Case Report |
|
Pertussis (Whooping Cough) |
CDPH 8258 (8/08) |
Pertussis Case Report |
|
Plague (Human) |
CDC 56.37 (2/06) |
Plague Case Investigation Report |
|
Poliovirus |
CDPH 8421 (7/07) |
Polio Virus Case Report |
|
Psittacosis |
CDPH 8583 (7/07) |
Psittacosis Case Report |
|
Q Fever |
CDPH 8558 (7/07) |
Case Report: Brucellosis; Q Fever; Tularemia |
|
Rabies, Human
Rabies, Animal |
CDPH 8526 (7/07)
PM 102 (5/07) |
Human Rabies Case Report
Animal Rabies Case Report |
|
Relapsing Fever |
CDPH 8560 (7/07)
|
Case Report: Typhus Fever; Relapsing Fever |
|
Reye Syndrome |
CDC 55.8 (9/91)
(scanned pdf 8/03) |
CDC Reye Syndrome Case Investigation Report
Note: Reporting is not mandated. |
|
Rocky Mountain Spotted Fever |
CDC 55.1 (1/08) |
Tick-Borne Rickettsial Disease Case Report
(For Rocky Mountain Spotted Fever (RMSF) |
|
Rubella (German Measles)
Rubella, Congenital Syndrome |
PM 358 (8/08)
CDC 71.17 (3/97)
|
Rubella (German Measles) Case Report
(Also see Measles on this list)
Congenital Rubella Syndrome Case Report |
|
Salmonella |
CDPH 8640 (10/08) |
Salmonella Case Report |
|
Staphylococcus aureus, Severe |
CDPH 9061 (10/08) |
Severe Staphylococcus aureus Infection in a Previously Healthy Person Case Report |
|
Syphilis |
CDPH 9063 (10/08) |
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). |
|
Tetanus |
Appendix 18 (6/03)
Appendix 18 Instructions |
Tetanus Surveillance Worksheet
Instructions for Completing the Tetanus Surveillance Worksheet |
|
Toxic Shock Syndrome |
CDC 52.3 (6/89)
(scanned pdf 8/03) |
Toxic Shock Syndrome Case Report |
|
Trichinosis |
CDC 54.7 (E) (4/03) |
Trichinosis Surveillance Case Report |
|
Tuberculosis |
CDPH 8620 A RVCT
CDPH 8620 B RVCT FU-1
CDPH 8620 C RVCT FU-2
CDPH 8635 A and B ARPE |
For all Tuberculosis Forms, see: Tuberculosis Reporting Forms and Instructions |
|
Tularemia |
CDPH 8558 (7/07) |
Case Report: Brucellosis; Q Fever; Tularemia |
|
Typhoid |
CDPH 8563 (7/07) English
DHS 8563 (SP) (5/99) Spanish
CDPH 8566 (7/07)
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 |
CDC 52.5 (6/97 PDF 10/03) |
Typhoid and Paratyphoid Fever Surveillance Report |
|
Typhus Fever |
CDPH 8560 (7/07) |
Case Report: Typhus Fever; Relapsing Fever |
|
Varicella (Chickenpox)
|
CDPH 8299 (10/08)
CDC (CDPH Revised)
CDC (5/11/98)
CDPH 9056 (8/08) |
Varicella (Chickenpox) Hospitalization Case Report
Varicella Death Investigation Worksheet
Varicella Death Investigation Worksheet - Instructions
Varicella Outbreak Report |
|
Vibrio Infections (non-Cholera) |
CDC 52.79 (8/07) |
Cholera and Other Vibrio Illness Surveillance Report |
|
West Nile Virus |
CDPH 8687 (6/08)
CDPH 8687 S (6/08) |
West Nile Virus (WNV) Infection Case Report
West Nile Virus (WNV) Supplemental Investigation Report |