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Acute Communicable Disease Control

    

Acute Communicable Disease Control


Contact Information
County of Los Angeles
Department of Public Health
Acute Communicable Disease Control
313 N. Figueroa Street, Room 212
Los Angeles, CA 90012
Phone: (213) 240-7941
Fax: (213) 482-4856
E-Mail:acdc2@ph.lacounty.gov
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Acute Communicable Disease Control
Epidemiologic Case History Forms

Forms are posted for information only. Except for certain conditions, non-public health healthcare providers are not expected to complete a questionnaire when reporting a condition.


Generate an Epidemiological Curve - Provides instructions and link for the excel file - (9-14-09)

DISEASE

FORM NAME

Amebiasis Parasite Epidemiologic Case History
Anaplasmosis Ehrlichiosis / Anaplasmosis Case Report
Anthrax Anthrax (Human) Case Report
Suspected Cutaneous Anthrax Case Investigation Form
Suspected Inhalation Anthrax Case Investigation Form
Anthrax Post-Exposure Epidemiologic Investigation Form
Babesiosis Babesiosis Case
Bioterrorism-Unspecified Illness Outbreak Gastrointestinal Illness Case Investigation Form
Fever/Rash Illness Case Investigation Form
Neurological Illness Case Investigation Form
Respiratory Illness Case Investigation Form
Botulism Botulism Case Report
Suspect Botulism Intake and Checklist
Specimen Submission Guidelines for Suspected Botulism
Brucellosis Brucellosis Case Report
Chickenpox (Hospitalized Cases and Deaths) Varicella (Chickenpox) Hospitalized Case Report
Varicella Death Investigation Worksheet
Instructions (for the Varicella Death Investigation Worksheet)
Cholera Cholera and Other Vibrio Illness Case Report
  CDC Cholera and Other Vibrio Illness Seafood Investigation Report Form (Section IV of COVIS, CDC 52.79 - seafood investigations only)
Ciguatera Fish Poisoning Outbreak/Unusual Disease Report
Colorado Tick Fever Outbreak/Unusual Disease Report
Creutzfeldt-Jakob Disease (CJD) and Transmissible Spongiform Encephalopathy (TSE) Creutzfeldt-Jakob Disease (CJD) and Transmissible Spongiform Encephalopathy (TSE) Case Report
Cryptosporidiosis Parasite Epidemiologic Case History
Cysticercosis (Taeniasis) Cysticercosis / Taeniasis Case Report
Cysticercosis (Taeniasis) Contact Work Sheet
Dengue (Break-Bone Fever) Dengue Case Report
Diphtheria Diphtheria Case Report
Domoic Acid (Amnesic Shellfish) Poisoning Outbreak/Unusual Disease Report
Ehrlichiosis Ehrlichiosis / Anaplasmosis Case Report
Foodborne Disease Outbreak Foodborne Disease Outbreak Report
  Instructions (for the Foodborne Disease Outbreak Report)
Giardiasis Parasite Epidemiologic Case History
Haemophilus Influenzae Invasive Haemophilus Influenzae Disease Case Report
Haemophilus Influenzae Type B Vaccine and Extended Information Worksheet
Hansen's disease (Leprosy) Leprosy Surveillance
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 or E Case Report
  Viral Hepatitis B or C Case Report
  Transfusion Associated Hepatitis Case Record
Hepatitis B, Perinatal Perinatal Hepatitis B Case Report
  Confidential HBsAg+ Case / Household Management Report
Influenza, Novel (includes Avian) Novel Influenza Case History Form (ACDC USE ONLY)
  Influenza or Other Respiratory Specimen Submittal Form
  Novel Influenza A (H5N1 and H7N9) Quicksheet
Influenza (Human) Fatal Influenza Fatality Case Report Form  
Legionellosis Legionellosis Case Report
Leprosy (Hansen's disease) Leprosy Surveillance
Leprosy Case/Contact Surveillance
Leptospirosis Leptospirosis Case Report
Listeriosis (Perinatal and Nonperinatal) Listeriosis Case Report (ACDC USE ONLY)
Listeriosis Case Abstraction Form  (ACDC USE ONLY)
Lyme Disease Lyme Disease Case Report
Malaria Malaria Case Report
Measles (Rubeola) Measles (Rubeola) Case Report
Melioidosis Melioidosis Intake Form
Meningococcal Infections Meningococcal Disease Case Report
Meningococcal Disease Contact Roster
  Meningococcal Case Supplemental Form
Mumps Mumps Case Report
Norovirus (outbreaks only) Norovirus Test Request Form
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
Outbreak - Health Care Facility (HF) CD Outbreak Investigation Acute Health Care Facility (ACDC USE ONLY)
CD Outbreak Investigation Sub-Acute Health Care Facility        (Instructions)
  Sample Line List - Gastrointestinal Illness Outbreak Line List - Patients and Employees
  Sample Line List - Respiratory Outbreak Line List for Residents and Staff
  Sample Line List - Scabies Outbreak
Outbreak-Norovirus Norovirus Test Request Form
Outbreak - Respiratory (Non-Health Care Facilities) Initial Report: Initial Assessment of Respiratory Outbreak Report
  Sample Line List-Respiratory Outbreaks for Students, Staff, or Residents
  Final Report: Acute Febrile Respiratory Illness Outbreak Report Form: Community and Congregate Settings
Outbreak - Waterborne Diseases  CDC NORS-Waterborne Diseases Outbreak Report Form (CDC 52.12):
          - Treated Recreational Water
          - Untreated Recreational Water
          - Water Intended for Drinking
          - Water Not Intended for Drinking or Water of Unknown Intent
          - Instructions for Completing CDC 52.12 
Paralytic Shellfish Poisoning Outbreak/Unusual Disease Report
Paratyphoid Fever Typhoid and Paratyphoid Fever Case Report
Pertussis (Whooping Cough) Pertussis Case Report
Pertussis Death Worksheet
Plague Plague (Human) Case Report
Pneumococcal, Invasive Disease Invasive Pneumococcal Disease Report Form
Poliomyelitis Poliomyelitis Case Report
Psittacosis Psittacosis Case Report
Q Fever Q Fever Case Report
Rabies Human Rabies Case Report
Rabies Exposure Form For Healthcare Workers
Relapsing Fever Relapsing Fever Case Report
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
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 Outbreak/Unusual Disease Report
Shiga Toxin-producing Escherichia coli (STEC) E. coli 0157, Other STEC, Shiga Toxin Positive Feces, and/ or HUS Case Report
Shigellosis Shigellosis Case Report
Smallpox (Variola) Worksheet: Evaluating Patients for Smallpox
Smallpox Post-Event Surveillance Form
Instructions (for the Smallpox Surveillance Form)
Staphylococcus aureus Infection, Severe Severe Staphylococcus aureus Infection in a Previously Health Person Case Report
Streptococcal Group A,  Invasive
(Including Streptococcal Toxic Shock Syndrome and Necrotizing Fasciitis)
Invasive Group A Streptococcal Disease (IGAS) Case Report
Streptococcus pneumoniae, Invasive Invasive Pneumococcal Disease Report Form
Tetanus Tetanus Surveillance Worksheet
Instructions (for the Tetanus Surveillance Worksheet
Supplemental injecting Drug Use Questionnaire for Tetanus Cases
Toxic Shock Syndrome (Staphylococcal) Toxic Shock Syndrome (Non-Streptococcal) Case Report
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 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 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)
Vibriosis Cholera and Other Vibrio Illness Case Report
  CDC Cholera and Other Vibrio Illness Seafood Investigation Report Form (Section IV of COVIS, CDC 52.79 - seafood investigations only)
West Nile Virus (WNV) Infection West Nile Virus (WNV) Infection Case Report
  West Nile Virus Infection Supplemental Form
West Nile Virus (WNV) Active Surveillance Laboratory Submittal Form
  West Nile Virus-Positive Blood Donor to the California Department of Public Health Report and Guidelines
Whooping Cough (Pertussis) Pertussis Case Report
  Pertussis Death Worksheet
Yellow Fever Yellow Fever Case Report
Yersiniosis Yersiniosis Form

 

 

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