Acute Communicable
Disease Control

 
Contact Information
County of Los Angeles
Department of Public Health
Acute Communicable Disease Control
313 N. Figueroa Street, #212
Los Angeles, CA 90012
Phone: (213) 240-7941
Fax: (213) 482-4856
Email: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.


CDC Quick Learn Lesson: Create an Epi Curve

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 (Human) Case Report
Suspected Cutaneous Anthrax Case Investigation Form
Suspected Inhalation Anthrax Case Investigation Form
Anthrax Post-Exposure Epidemiologic Investigation Form
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)
  Viral Hemorrhagic Fever Exposure Daily Symptom Monitoring Log (Form D)
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) Hansenís 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)  
  Viral Hemorrhagic Fever Exposure Daily Symptom Monitoring Log (Form D)
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  
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 FacilityInstructions
  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)
Supplemental injecting Drug Use Questionnaire for Tetanus Cases
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 
   
   

 

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Public Health has made reasonable efforts to provide accurate translation. However, no computerized translation is perfect and is not intended to replace traditional translation methods. If questions arise concerning the accuracy of the information, please refer to the English edition of the website, which is the official version.
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