|
DISEASE |
FORM NAME |
|
Acute Flaccid Myelitis |
Acute Flaccid Myelitis: Patient Case
Summary Form |
|
|
Instructions for Completing the AFM
Patient Summary Form |
|
Anaplasmosis |
Ehrlichiosis / Anaplasmosis Case Report |
|
Anthrax
|
Anthrax Case Investigation Form (Individual) |
|
|
Anthrax Case Report (Outbreak)
|
|
Babesiosis |
Babesiosis
Case |
|
Botulism
|
Botulism
Case Report |
|
|
Suspect Botulism
Intake and Checklist |
|
|
Specimen Submission Guidelines for Suspected Botulism |
|
|
Suspect Foodborne of Unknown Etiology Botulism Case
Interview Form |
|
|
Home Inspection Guide for Suspected Foodborne Botulism |
|
Brucellosis
|
Brucellosis
Case Report |
|
Candida auris |
Candida auris Report Form |
|
Carbapenem-resistant Enterobacteriaceae (CRE) |
Carbapenem-resistant Enterobacteriaceae (CRE) Case Report
Form (SNFs only) |
|
Chagas Disease |
Chagas Disease Case History Form
(REDCap form for ACDC USE ONLY) |
|
|
Chagas Disease Form for Non-Confirmed Cases (REDCap form for ACDC USE ONLY ) |
|
Chickenpox (Hospitalized Cases and Deaths)
|
Varicella
(Chickenpox) Hospitalized
Case Report |
|
|
Varicella Death Investigation Worksheet |
|
|
Instructions
(for the Varicella Death Investigation Worksheet) |
|
Chickenpox (Varicella) Outbreaks
|
Varicella (Chickenpox) Outbreak Worksheet (Excel) |
|
Chikungunya |
Chikungunya Case Report |
|
Cholera |
Cholera and Other Vibrio Illness Case Report |
|
|
CDC
Cholera and Other Vibrio Illness Seafood Investigation Report
Form (Section 5 of COVIS, CDC OMB 0920-0728 - seafood investigations
only) |
|
Ciguatera Fish Poisoning |
Seafood
Poisonings |
|
|
|
|
Coronavirus Disease 2019 (COVID-19) |
Provider and Laboratory Reporting Guidelines
webpage |
|
|
Multisystem Inflammatory Syndrome in Children Associated with SARS-CoV-2 Infection Case Report Form |
|
CRE (Carbapenem-resistant Enterobacteriaceae) |
Carbapenem-resistant Enterobacteriaceae (CRE) Case Report
Form (SNFs only) |
|
Creutzfeldt-Jakob Disease (CJD)
and Transmissible Spongiform Encephalopathy (TSE) |
CJD and TSE Case
Report |
|
Cronobacter Infection, Invasive (Infants: <12 months) |
Invasive
Cronobacter Infection in Infants Case Report Form |
|
Cryptosporidiosis (outbreaks only) |
Outbreak/Unusual Disease Report |
|
Cyclosporiasis |
Cyclosporiasis Surveillance Case Report Form |
|
|
Cyclosporiasis National Hypothesis Generating Questionnaire
|
|
Cysticercosis (Taeniasis) |
Cysticercosis
/ Taeniasis Case Report |
|
|
Cysticercosis (Taeniasis) Contact Work Sheet |
|
Dengue
(Break-Bone Fever) |
Dengue/Severe
Dengue
Case Report |
|
Diphtheria
|
Diphtheria
Case Report |
|
Domoic Acid (Amnesic Shellfish) Poisoning |
Seafood
Poisonings |
|
Ebola Virus Disease |
AOD Suspect Viral Hemorrhagic Fever Intake and Checklist
|
|
|
Ebola Virus Disease PUI/Case Comprehensive Intake Form (Form A) |
|
|
Viral Hemorrhagic Fever Contact Investigation Worksheet (Form B) |
|
|
Viral Hemorrhagic Fever Case Report (ACDC USE ONLY)
(Form C) |
|
Ehrlichiosis
|
Ehrlichiosis / Anaplasmosis Case Report |
|
Foodborne
Disease Outbreak |
Foodborne
Disease Outbreak Report |
|
|
Instructions (for the Foodborne Disease Outbreak Report) |
|
Giardiasis |
Parasite
Epidemiologic Case History Form |
|
Glanders |
Glanders and Melioidosis Case Report Form |
|
|
Parasite Contact Roster |
|
Haemophilus Influenzae
|
Invasive
Haemophilus Influenzae Disease Case Report |
|
Hansen's
disease (Leprosy) |
Hansen’s Disease (Leprosy) Surveillance Form |
|
|
Leprosy
Case/Contact Surveillance |
|
Hantavirus
Infections |
Hantavirus Infections Case Report |
|
|
Hantavirus
Pulmonary Syndrome Screening Form |
|
Hemolytic
Uremic Syndrome (HUS) |
E. coli 0157, Other STEC, Shiga Toxin Positive Feces,
and/ or HUS Case Report |
|
Hepatitis, Viral |
Viral
Hepatitis A Case Report |
|
|
Hepatitis A Enhanced Interview |
|
|
Hepatitis A Close Contact Worksheet |
|
|
Hepatitis A Exposure Site Contact Worksheet |
|
|
Viral Hepatitis B Case Report |
|
|
Viral Hepatitis C Case Report |
|
|
Perinatal
Hepatitis C Case Report |
|
|
Viral Hepatitis E Case Report |
|
Hepatitis
B, Perinatal |
Confidential HBsAg+ Case / Household Management Report
(PERINATAL HEPATITIS B PREVENTION UNIT
USE ONLY) |
|
Influenza, Novel (includes Avian) |
Human Infection with Novel Influenza A Virus Case
Report Form (ACDC USE ONLY) |
|
Influenza (Human) Fatal |
Influenza-Associated Death Case Report Form |
|
Legionellosis
|
Legionellosis Case Report |
|
Leprosy (Hansen's disease) |
Leprosy
Surveillance |
|
Leptospirosis
|
Leptospirosis Case Report |
|
Listeriosis |
Listeriosis Case
Report (ACDC USE ONLY) |
|
|
Neonatal Listeriosis Case Report (ACDC USE ONLY) |
|
Lyme Disease
|
Lyme Disease Case Report |
|
Malaria
|
Malaria Case Report |
|
Marburg Virus Disease |
AOD Suspect Viral Hemorrhagic Fever Intake and Checklist
|
|
|
Viral Hemorrhagic Fever Contact Investigation Worksheet (Form
B) |
|
|
Viral Hemorrhagic Fever Case Report (Form C) (ACDC USE ONLY) |
|
Measles (Rubeola)
|
Measles
(Rubeola)
Case Report |
|
|
Measles Exposure Interview Form |
|
Melioidosis |
Glanders and Melioidosis Case Report Form |
|
Meningococcal Infections |
Suspect Meningococcal Disease Intake and Checklist (for AOD and
COD) |
|
|
Meningococcal Disease Case Report
|
|
|
Meningococcal Disease Contact Roster
|
|
|
Meningococcal Case Supplemental Form
(ACDC USE ONLY) |
|
Middle East Respiratory Syndrome (MERS) |
Middle East Respiratory Syndrome (MERS) Patient Under
Investigation (PUI) Short Form |
|
Monkeypox |
See
Mpox Information for Health Providers
webpage |
|
Mumps |
Mumps Case Report |
|
Myelitis, Acute Flaccid |
Acute Flaccid Myelitis: Patient Case
Summary Form |
|
|
Instructions for Completing the AFM Patient Summary |
|
Nipah Virus Disease |
AOD Suspect Nipah Intake and Checklist |
|
|
Nipah Virus Disease Case Report Form |
|
|
Nipah Virus Disease Exposure Daily
Symptom Monitoring Log |
|
|
Nipah Virus Disease Contact
Investigation Worksheet for Symptomatic
Suspect or Confirmed Cases |
|
Non-Tuberculous Mycobacterium, Extrapulmonary Form |
Extrapulmonary Non-Tuberculous
Mycobacterium (NTM) Report |
|
Norovirus (outbreaks only) |
Norovirus
Test Request Form |
|
Outbreaks - Coronavirus Disease 2019 (COVID-19) |
|
|
Healthcare Facilities: |
Outbreak Investigation General Acute Care Hospital -
Instructions |
|
|
- Acute Psychiatric Hospitals
webpage
for details.
- Long-Term Healthcare Facilities (LTHFs)- SNFs, ICFs, CLHFs
webpage for details.
(Outbreak forms are NOT required for COVID-19 LTHFs outbreaks.) |
|
Community Settings: |
See
webpage for details. (Outbreak forms are NOT required for COVID-19 Community outbreaks.)
Examples include:
- Education settings
- Community care facilities
- Sites serving people experiencing homelessness (PEH)
- Correctional/detention facilities
- Workplace settings
|
|
|
|
Outbreak - Foodborne Diseases |
Foodborne
Disease Outbreak Report |
|
|
Instructions (for the Foodborne Disease Outbreak Report) |
|
Outbreak - General or Non-Health Care Facility |
Outbreak/Unusual Disease Report |
|
|
Respiratory/Influenza: |
|
|
-Acute
Respiratory Illness Outbreak Report -
Non-healthcare
|
|
|
-Influenza/Respiratory Outbreak
Line List for Non-___Healthcare
Facilities-Students, Staff, Residents-----------(PDF/Excel) |
|
|
Varicella (Chickenpox) Outbreak Worksheet (Excel) |
|
Outbreak - Health Care Facility (HF) |
Outbreak
Investigation General Acute Care Hospital -
Instructions
(ACDC USE ONLY) |
|
|
CD Outbreak
Investigation Sub-Acute Health Care Facility- Instructions |
|
|
Sample Outbreak Line Lists: |
|
|
-Gastrointestinal Illness/Norovirus-Patients/Residents & Staff (PDF/Excel) |
|
|
-Influenza/Respiratory-Residents & Staff (PDF/Excel) |
|
|
-Scabies-Patients & Employees (PDF/Excel) |
|
Outbreak - Waterborne Diseases |
NORS-Waterborne Disease
Transmission Form (CDC 52.12) |
|
|
-
Instructions for Completing CDC 52.12 |
|
Paralytic Shellfish Poisoning |
Seafood Poisonings |
|
Paratyphoid Fever |
Typhoid and Paratyphoid Fever
Case Report |
|
|
Release of Acute or Convalescent Typhoid/Paratyphoid Fever
Case |
|
Pertussis
(Whooping Cough) |
Pertussis Case Report |
|
|
Pertussis Death Worksheet |
|
|
Pertussis Death Worksheet Instructions |
|
Plague
|
Plague
(Human) Case Report |
|
Pneumococcal, Invasive Disease
|
Invasive
Group A Streptococcal (GAS) or Pneumococcal Disease Report Form
|
|
Poliomyelitis
|
Poliomyelitis Case Report |
|
Psittacosis |
Psittacosis Case Report |
|
Q Fever |
Q
Fever Case Report |
|
Rabies
|
Human Rabies Case Report |
|
Relapsing Fever
|
Relapsing Fever
Case Report |
|
Respiratory Syncytial Virus (Fatal <5 years) |
Respiratory Syncytial Virus (RSV) Death Form < 5 years |
|
Rocky Mountain Spotted Fever |
Spotted Fever Rickettsioses Case Report |
|
Rubella (German Measles,
3-day measles) |
Rubella
(German Measles)
Case Report |
|
Rubella Syndrome, Congenital |
Congenital Rubella Syndrome Case Report |
|
Salmonellosis |
Salmonellosis
Case Report and Contact Roster |
|
|
Salmonellosis Contact Roster Fillable |
|
SARS (Severe Acute Respiratory Syndrome) |
SARS
Domestic Case Reporting
Form |
|
Scabies (atypical or crusted in a non-health facility) |
Outbreak/Unusual Disease Report |
|
Scombroid Fish Poisoning |
Seafood Poisonings |
|
Shiga Toxin-producing Escherichia coli (STEC) |
Shiga Toxin-Producing Escherichia coli (STEC) and/or
Hemolytic Uremic Syndrome (HUS) Case Report |
|
|
Additional
Ill Contacts and
Household Contacts are now contained within the STEC Case
Report Form |
|
Shigellosis |
Shigellosis Case Report |
|
|
Additional
Ill Contacts and
Household Contacts are now contained within the Shigellosis Case
Report Form |
|
Smallpox (Variola) |
Worksheet: Evaluating Patients for Smallpox |
|
|
Smallpox Post-Event Surveillance Form |
|
|
Instructions
(for the Smallpox Surveillance Form) |
|
St. Louis Encephalitis Virus Infection |
West Nile Virus Case History Report |
Streptococcal Group A,
Invasive
(Including Streptococcal Toxic Shock Syndrome and
Necrotizing Fasciitis) |
Invasive
Group A Streptococcal (GAS) or Pneumococcal Disease Report Form
|
|
Streptococcus pneumoniae, Invasive |
Invasive
Group A Streptococcal (GAS) or Pneumococcal Disease Report Form
|
|
Tetanus
|
Tetanus Surveillance Worksheet |
|
|
Instructions
(for the Tetanus Surveillance Worksheet) |
|
Trichinosis |
Trichinosis Case Report |
|
Tularemia
(Rabbit Fever) |
Tularemia Case Report |
|
Typhoid Fever, Acute |
Typhoid and Paratyphoid Fever
Case Report |
|
|
Release of Acute or Convalescent Typhoid/Paratyphoid Fever Case |
|
Typhoid Fever, Carrier |
Typhoid Carrier Agreement
(English &
Spanish) |
|
|
Typhoid Carrier Semi-Annual Report |
|
|
Typhoid Carrier Register -- Semi-Annual Update |
|
|
Release of Chronic Typhoid Carrier |
|
|
Typhoid Carrier Case Report |
|
Typhus Fever and Other Non-Spotted Fever Rickettsioses |
Typhus and Other Non-Spotted Fever Rickettsioses Case Report
|
|
Vaccine Adverse Event Report (VAERS) |
Vaccine Adverse Event Report
(VAERS) |
|
Varicella
(Hospitalized
Cases and Deaths)
|
Varicella
(Chickenpox) Hospitalized
Case Report |
|
|
Varicella Death Investigation Worksheet |
|
|
Instructions
(for the Varicella Death Investigation Worksheet) |
|
Varicella Outbreaks |
Varicella (Chickenpox) Outbreak Worksheet (Excel) |
|
Vibriosis |
Cholera and Other Vibrio Illness Case Report |
|
|
CDC
Cholera and Other Vibrio Illness Seafood Investigation Report
Form (Section 5 of COVIS, CDC OMB 0920-0728 - seafood investigations
only) |
|
West Nile Virus (WNV) Infection |
West
Nile Virus Case History Report |
|
|
Report of WNV/SLEV-Positive Blood Donor to the CDPH |
|
Whooping Cough
(Pertussis) |
Pertussis Case Report |
|
|
Pertussis Death Worksheet |
|
Yellow Fever |
Yellow
Fever Case Report |
|
Yersiniosis
|
Yersiniosis
Form |
|
Zika Virus Disease |
Zika
Case Report |
|
|
|
|
|
|
