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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

​Anthrax (Human) CDPH 8578 (PDF) ​Anthrax (Human) Case Report
​Babesiosis CDPH 8270 (PDF) ​Babesiosis Case Report
​Botulism (Food or Wound) CDPH 8547 (PDF) ​Botullism Case Report
​Brucellosis CDPH 8607 (PDF) ​Brucellosis Case Report
​Chikungunya CDPH 8618 (PDF) ​Chikungunya Case Report
​Cholera and Other Vibrio Illness

CDPH 8587 (PDF)

CDC OMB 0920-0728 (PDF)

​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 (PDF) ​Coccidioidomycosis Case Report
​Creutzfeldt-Jakob Disease (CJD) and Transmissible Spongiform Encephalopathy (TSE) CDPH 9002 (PDF) ​Creutzfeldt-Jakob Disease (CJD) and Transmissible Spongiform Encephalopathy (TSE) Case Report
​Cyclosporiasis CDC 54.48 (PDF) ​Cyclosporiasis Surveillance Case Report
​Cysticercosis CDPH 8581 (PDF) ​Cysticercosis/Taeniasis Case Report
​Dengue and Severe Dengue CDPH 8670 (PDF) ​Dengue Case Report
​Diphtheria CDPH 8579 (PDF) ​Diphtheria Case Report
​Ehrlichiosis/Anaplasmosis CDPH 8573 (PDF) ​Ehrlichiosis/Anaplasmosis Case Report
​E. coli O157, Other STEC, Shiga Toxin Positive Feces, and/or HUS CDPH 8555 (PDF) ​E. coli O157, Other STEC, Shiga Toxin Positive Feces, and/or HUS Case Report
​Guillian-Barre' Syndrome CDPH 9073 (PDF) ​Guillian-Barre' Syndrome (GBS) Surveillance Case Report
​Gonorrhea CDPH 9064 (PDF)

​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 (PDF) ​Invasive Haemophilus Influenzae Disease Case Report
​Hantavirus CDPH 9077 (PDF) ​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

Or

Hepatitis C, Acute

CDPH 8703 (PDF) ​Acute Hepatitis B or C Case Report
​Hepatitis E CDPH 8701 (PDF) ​Hepatitis E Case Report
​Influenza, Severe CDPH 9070 (PDF) ​Severe Influenza Case History Form (ICU and Fatal Cases Age 0-64 Years)
​Influenza, Novel CDC OMB 0920-0004 (PDF) ​Novel Influenza Case History Form
​Legionellosis CDPH 8588 (PDF) ​Legionellosis Case Report
​Leprosy (Hansen's Disease) NHDP ​Hansen's Disease Surveillance
​Leptospirosis CDPH 8577 (PDF) ​Leptospirosis Case Report
​Listeriosis

CDPH 8296 (PDF)

CDC OMB 0920-0728 (PDF)

​Listeriosis Case Report

CDC Listeria Initiative Case Report

​Lyme Disease CDPH 8470 (PDF) ​Lyme Disease Case Report
​Malaria CDPH 8657 (PDF) ​Malaria Case Report
Measles (Rubeola) CDPH 8345 (PDF) ​Measles (Rubeola) Case Report-California (also see Rubella (German Measles) in this list)
​Meningococcal Infections

CDPH 8469 (PDF)

Meningococcal Contact-Follow Up Sheet (PDF)

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

CDPH 8258 (PDF)

CDPH 8263 (PDF)

​Pertussis Case Report

Pertussis Supplemental Form-cases <4 months of age

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

​Rabies, Human

Rabies, Animal

CDPH 8526 (PDF)

CDPH 102 (PDF)

​Human Rabies Case Report

Animal Rabies Case Report

​Relapsing Fever

CDPH 8561 (PDF) ​Relapsing Fever Case Report
​Reye Syndrome CDC 55.8 (PDF)

​CDC Reye Syndrome Case Investigation Report

Note: Reporting is not mandated

​Rocky Mountain Spotted Fever CDPH 8575 (PDF) ​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-Also see Measles on this list

​Congenital Rubella Syndrome Case Report

​Salmonellosis CDPH 8640 (PDF) ​Salmonellosis Case Report
​Shigellosis CDPH 8639 (PDF) ​Shigellosis Case Report
​Spotted Fever Rickettsioses (Including Rocky Mountain Spotted Fever) CDPH 8575 (PDF) ​Spotted Fever Rickettsioses Case Report
​Staphylococcus Aureus, Severe (Community-Associated) CDPH 9061 (PDF) ​Severe Staphylococcus Aureus Infection, (Community-Associated) Case Report

​Syphilis

 

 

 

 

CDPH 9049 (PDF)

CDPH 9040 (PDF)

CDPH 9063 (PDF)

 

 

California Congenital Syphilis (CS) Case Investigation and Report

​Out of State Syphilis Record Search Request

California Syphilis Interview Record

This form is posted for informational purposes. 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 (PDF) ​Cysticercosis/Taeniasis Case Report
​Tetanus

CDPH 8619 (PDF)

Appendix 18 (PDF)

Appendix 18 Instructions (PDF)

​Supplemental Injecting Drug Use Questionnaire for Tetanus Cases

Tetanus Surveillance Worksheet

Tetanus Surveillance Worksheet Instructions

​Toxic Shock Syndrome (Non-Streptococcal)

CDPH 8599 (PDF)

​Toxic Shock Syndrome (Non-Streptococcal) Case Report

​Trichinosis CDPH 8606 (PDF) ​Trichinosis Case Report
​Tuberculosis

CDPH 8620 A RVCT (PDF)

CDPH 8620 B RVCT FU-1 (PDF)

CDPH 8620 C RVCT FU-2 (PDF)

CDPH 8635 A-B ARPE (PDF) | Instructions

Tuberculosis Forms
​Tularemia CDPH 8559 (PDF) ​Tularemia Case Report
​Typhoid Carrier

CDPH 8563 (PDF)

CDPH 8566 (PDF)

CDPH 8466 (PDF)

​Typhoid Carrier Agreement

Typhoid Carrier Case Report

Typhoid Carrier-Register-Semiannual Update

​Typhoid and Paratyphoid Fever CDPH 8586 (PDF) ​Typhoid and Paratyphoid Fever Case Report
​Typhus and Other Non-Spotted Fever Rickettsioses CDPH 8580 (PDF) ​Typhus and Other Non-Spotted Fever Rickettsioses Case Report
​Varicella (Chickenpox)

CDPH 8299 (PDF)

CDC (CDPH Revised)

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 (PDF)

CDC OMB 0920-0728 (PDF)

​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 CDPH 8527 (PDF) ​Viral Hemorrhagic Fever Case Report
​Viral Hemorrhagic Fever (Animal) CDPH 8528 (PDF) ​Viral Hemorrhagic Fever (Animal) Case Report
​West Nile Virus

CDPH 8687 (PDF)

CDPH 8687 A (PDF)

​West Nile Virus (WNV) Infection Case Report

West Nile Virus (WNV) Infection Case Report-Supplemental Investigation Form

​Yellow Fever CDPH 8584 (PDF) ​Yellow Fever Case Report
​Zika CDPH 8680 (PDF) ​Zika Case Report

 

Outbreak-Disease Report Forms and Related Documents

(Two or more cases from a common source)

 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)

 

CDPH 8567 Instructions (PDF)

 

 

 

 

​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

 

​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) ​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 Number

 Form Title

​Confidential Morbidity Report (CMR) CDPH 110 A (PDF) ​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) ​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 (PDF) ​Confidential Morbidity Report for Animal Patients (CMR). Use this form for reporting conditions in animal patients.
​Ebola-Emergency Department or Flight Contact Interview Form CDPH 8525 (PDF) ​Emergency Department or Flight Contact to Ebola Patient Interview Form
​Ebola-Healthcare Worker Contact Interview Form CDPH 8530 (PDF) ​Healthcare Worker (HCW) Contact to Ebola Patient Interview Form
​Ebola-Household/Other Community Contact Interview Form CDPH 8535 (PDF) ​Household or Other Community Contact to Ebola Patient Interview Form
​Interstate Reciprocal Notification of Disease for Reporting Out-of-State Cases CDC 42.1 e (PDF) ​Interstate Reciprocal Notification of Disease
​Other Reportable Diseases or Disease of Unusual Occurrence (for any diseases or outbreaks) CDPH 8554 (PDF) ​Other Outbreak; Other Reportable Disease or Disease of Unusual Occurrence
​Request for DataCDPH 9078 (PDF)​Request for Infectious Diseases Branch Surveillance Data
​STD Health Department Follow-UpCDPH 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.

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