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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Other Report and Data Forms

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Infectious Diseases Case Report Forms

Foodborne Disease Outbreaks

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