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)
Acute Flaccid Myelitis (AFM)	N/A	AFM Patient Summary Form
Anaplasmosis	CDPH 9154	Anaplasmosis Case report Form
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 Virus Infection	CDPH 8670	Dengue Virus Infection Case Report
Diphtheria	CDPH 8579	Diphtheria Case Report
Ehrlichiosis	CDPH 8573	Ehrlichiosis Case Report
Guillian-Barre’ Syndrome	CDPH 9073	Guillian-Barre’ 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 (Hansen’s Disease)	NHDP	Hansen’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	CDC CS 342427-A CDPH 8528	CDC 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)

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

Form	Form Number	Form Title
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

Form

Form Number

Form Title

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

Form	Form Number	Form Title
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.

Page Last Updated : March 4, 2025

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Outbreak-Disease Report Forms and Related Documents

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Foodborne Disease Outbreaks

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Other Report and Data Forms

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