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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
 ​Chikungunya Case Report

A fillable PDF is available in the CalREDIE Document Repository.
​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 OMB 0920-1198 (PDF)
 ​Cyclosporiasis Surveillance Case Report
​Cysticercosis ​CDPH 8581 (PDF) ​Cysticercosis/Taeniasis Case Report
​Dengue and Severe Dengue ​CDPH 8670
 ​Dengue and Severe Dengue Case Report
A fillable PDF is available in the CalREDIE Document Repository.
​Diphtheria ​CDPH 8579 (PDF) ​Diphtheria Case Report
​Ehrlichiosis/Anaplasmosis ​CDPH 8573
 ​Ehrlichiosis/Anaplasmosis Case Report
A fillable PDF is available in the CalREDIE Document Repository.
​Guillian-Barre' Syndrome ​CDPH 9073 (PDF) ​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 ​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 C, Perinatal
 ​CDPH 8704 (PDF)
 ​Perinatal Hepatitis 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)
​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)

CDPH 8297 (PDF)

​Listeriosis Case Report

Neonatal Listeriosis 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
 ​Spotted Fever Rickettsioses Case Report
A fillable PDF is available in the CalREDIE Document Repository.
​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
 ​Salmonellosis Case Report
A fillable PDF is available in the CalREDIE Document Repository.
​Shiga Toxin-Producing Escherichia coli (STEC) and/or Hemolytic Uremic Syndrome (HUS) ​CDPH 8555 (PDF) ​Shiga Toxin-Producing Escherichia coli (STEC) and/or Hemolytic Uremic Syndrome (HUS) Case Report
​Shigellosis ​CDPH 8639 (PDF) ​Shigellosis Case Report
​Spotted Fever Rickettsioses (Including Rocky Mountain Spotted Fever) ​CDPH 8575
 ​Spotted Fever Rickettsioses Case Report
A fillable PDF is available in the CalREDIE Document Repository.
​Staphylococcus Aureus, Severe (Community-Associated) ​CDPH 9061 (PDF) ​Severe Staphylococcus Aureus Infection, (Community-Associated) 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 (PDF) ​Cysticercosis/Taeniasis Case Report
​Tetanus

​Appendix 18 (PDF)

Appendix 18 Instructions (PDF)

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)

 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 Case Report
 ​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)​

​West Nile Virus (WNV) Infection Case Report
​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 110 D (PDF)
 ​Only use this form for reporting COVID-19 only.
​ ​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 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.

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