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
|
|---|---|---|
|
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 |
| 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
|
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) |
Foodborne Disease Outbreaks
Form
|
Form Number |
Form Title |
|---|---|---|
|
Foodborne Disease Outbreak Report
|
|
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.