Fillable CONFIDENTIAL MORBIDITY REPORT (HSA)

Fill Online, Printable, Fillable, Blank CONFIDENTIAL MORBIDITY REPORT (HSA) Form

Use Fill to complete blank online HSA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

CONFIDENTIAL MORBIDITY REPORT (HSA)

On average this form takes 33 minutes to complete

The CONFIDENTIAL MORBIDITY REPORT (HSA) form is 4 pages long and contains:

  • 0 signatures
  • 145 check-boxes
  • 65 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your HSA forms online.

BROWSE HSA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
DISEASE BEING REPORTED
CONFIDENTIAL MORBIDITY REPORT
PLEASE NOTE: Use this form for reporting all conditions except Tuberculosis and conditions reportable to DMV.
State of California—Health and Human Services Agency California Department of Public Health
Treated in office Given prescription
SEXUALLY TRANSMITTED DISEASES (STDs)
If reporting Syphilis, Stage:
Primary (lesion present)
Secondary
Early, non-primary, non-secondary
Unknown Duration or Late
Congenital
Syphilis Test Results
RPR
If reporting Chlamydia and/or Gonorrhea:
Specimen Source(s) Symptoms?
(check all that apply)
Cervical
Pharyngeal
Rectal
Urethral
Urine
Vaginal
Yes
No
VIRAL HEPATITIS
Diagnosis (check all that apply)
Hepatitis A
Hepatitis B (acute)
Hepatitis B (chronic)
Hepatitis B (perinatal)
Hepatitis C (acute)
Hepatitis C (chronic)
Hepatitis D
Hepatitis E
Is patient symptomatic?
Yes No Unknown
Pos Neg
HBsAg
anti-HBc total
anti-HBc IgM
anti-HBs
HBeAg
anti-HBe
anti-HAV IgM
Pos Neg
RIBA
(e.g., PCR)
anti-HDV
anti-HEV
anti-HCV
HCV RNA
CDPH 110a (03/18) (for reporting all conditions except Tuberculosis and conditions reportable to DMV)
Page 1 of 4
Unknown
Hep C
Hep D
Hep E
Hep A
Hep B
HBV DNA: ___________
Suspected Exposure Type(s)
Blood transfusion, dental or
medical procedure
IV drug use
Other needle exposure
Sexual contact
Household contact
Perinatal
Child care
Other: _______________
ALT (SGPT)
AST (SGOT)
Bilirubin result: ____________
Upper
Result: _____ Limit: _____
Upper
Result: _____ Limit: _____
Other: _________
Gender of Sex Partners
(check all that apply)
Male M to F Transgender
Female
Unknown
STD TREATMENT
Drug(s), Dosage, Route
Treatment Began
(mm/dd/yyyy)
Untreated
Will treat
Unable to contact patient
Patient refused treatment
Referred to: ____________
F to M Transgender
Other: __________
Partner(s) Treated?
Yes, treated in this clinic
Yes, Meds/Prescription given to
patient for their partner(s)
No, instructed patient to refer
partner(s) for treatment
No, referred partner(s) to:
Unknown
Pos Neg
Titer
_____
VDRL
Pos Neg
_____
FTA-ABS
Pos Neg
TP-PA
Pos Neg
EIA/CLIA
Pos Neg
CSF-VDRL
Pos Neg
_____
Other: ____________________
Yes, other: ______________
Primary
Language
Patient Name - Last Name
Home Address: Number, Street
City
Home Telephone Number
First Name MI
Apt./Unit No.
State ZIP Code
Cell Telephone Number Work Telephone Number
Birth Date (mm/dd/yyyy)
Age
Years
Months
Days
Gender
Male
Female
Pregnant?
Est. Delivery Date (mm/dd/yyyy)
Yes No Unknown
Country of Birth
Ethnicity (check one)
Race (check all that apply)
Hispanic/Latino Non-Hispanic/Non-Latino Unknown
African-American/Black
American Indian/Alaska Native
Asian (check all that apply)
Asian Indian Hmong Thai
VietnameseJapaneseCambodian
Other (specify):
KoreanChinese
LaotianFilipino
Pacific Islander (check all that apply)
SamoanNative Hawaiian
Other (specify): ________
Guamanian
White
Other (specify): _______________
Unknown
Occupational or Exposure Setting (check all that apply):Occupation or Job Title
Food Service Day Care Health Care
Correctional Facility School
Other (specify): _______________________________________
Date of Onset (mm/dd/yyyy) Date of First Specimen Collection (mm/dd/yyyy) Date of Diagnosis (mm/dd/yyyy) Date of Death (mm/dd/yyyy)
Reporting Health Care Provider
Address: Number, Street Suite/Unit No.
City
Telephone Number
State ZIP Code
Fax Number
Date Submitted (mm/dd/yyyy)
Submitted by
Laboratory Name City State ZIP Code
REPORT TO:
(Obtain additional forms from your local health department.)
M to F Transgender
F to M Transgender
Other: ____________
Reporting Health Care Facility
Email Address
English Spanish
Other: ______________
Remarks:
Clinical Manifestations?
Neurologic
Late clinicalOcular
Otic
County of Santa Cruz
Communicable Disease Unit
1060 Emeline Ave., Bldg F
Santa Cruz, CA 95060
Phone: (831) 454-4114/FAX: (831) 454-5049
After 5:00pm/Weekends/Holidays
Phone: (831) 471-1170
Page 2 of 4
Title 17, California Code of Regulations (CCR) §2500, §2593, §2641.5-2643.20,
and §2800-2812 Reportable Diseases and Conditions*
§ 2500. REPORTING TO THE LOCAL HEALTH AUTHORITY.
•
§ 2500(b) It shall be the duty of every health care provider, knowing of or in attendance on a case or suspected
case of any of the diseases or condition listed below, to report to the local health officer for the jurisdiction where
the patient resides. Where no health care provider is in attendance, any individual having knowledge of a person
who is suspected to be suffering from one of the diseases or conditions listed below may make such a report to
the local health officer for the jurisdiction where the patient resides.
•
§ 2500(c) The administrator of each health facility, clinic, or other setting where more than one health care
provider may know of a case, a suspected case or an outbreak of disease within the facility shall establish and be
responsible for administrative procedures to assure that reports are made to the local officer.
•
§ 2500(a)(14) "Health care provider" means a physician and surgeon, a veterinarian, a podiatrist, a nurse
practitioner, a physician assistant, a registered nurse, a nurse midwife, a school nurse, an infection control
practitioner, a medical examiner, a coroner, or a dentist.
URGENCY REPORTING REQUIREMENTS [17 CCR §2500(h)(i)]
✆ ! =
Report immediately by telephone (designated by a ♦ in regulations).
† = Report immediately by telephone when two or more cases or suspected cases of foodborne
disease from separate households are suspected to have the same source of illness (designated
by a • in regulations).
✆ =
Report by telephone within one working day of identification (designated by a + in regulations).
FAX ✆ ✉ =
Report by electronic transmission (including FAX), telephone, or mail within one working day of
identification (designated by a + in regulations).
WEEK = All other diseases/conditions should be reported by electronic transmission (including FAX),
telephone, or mail within seven calendar days of identification.
REPORTABLE COMMUNICABLE DISEASES §2500(j)(1)
Disease Name Urgency Disease Name Urgency
Amebiasis
FAX ✆ ✉
Listeriosis
FAX ✆ ✉
Anaplasmosis WEEK Lyme Disease WEEK
Anthrax, human or animal
✆ !
Malaria
FAX ✆ ✉
Babesiosis
FAX ✆ ✉
Measles (Rubeola)
✆ !
Botulism (Infant, Foodborne, wound,
Other)
✆ !
Meningitis, Specify Etiology: Viral,
Bacterial, Fungal, Parasitic
FAX ✆ ✉
Brucellosis, animal (except
infections due to Brucella canis)
WEEK
Meningococcal Infections
✆ !
Brucellosis, human
✆ !
Mumps WEEK
Campylobacteriosis
FAX ✆ ✉
Novel Virus Infection with
Pandemic Potential
✆ !
Chancroid
WEEK
Paralytic Shellfish Poisoning
✆ !
Chickenpox (Varicella) (outbreaks,
hospitalizations and deaths)
FAX ✆ ✉
Pertussis (Whooping Cough)
FAX ✆ ✉
Chikungunya Virus Infection
FAX ✆ ✉
Plague, human or animal
✆ !
Chlamydia trachomatis infections,
including lymphogranuloma
venereum (LGV)
WEEK
Poliovirus Infection
FAX ✆ ✉
CDPH 110a (03/18)
Page 3 of 4
Disease Name Urgency Disease Name Urgency
Cholera
✆ !
Psittacosis
FAX ✆ ✉
Ciguatera Fish Poisoning
✆ !
Q Fever
FAX ✆ ✉
Coccidioidomycosis WEEK Rabies, human or animal
✆ !
Creutzfeldt-Jakob Disease (CJD) and
other Transmissible Spongiform
Encephalopathies (TSE)
WEEK
Relapsing Fever
FAX ✆ ✉
Cryptosporidiosis
FAX ✆ ✉
Respiratory Syncytial Virus (only report
a death in a patient less than less than
five years of age)
WEEK
Cyclosporiasis
WEEK
Rickettsial Diseases (non-Rocky
Mountain Spotted Fever), including
Typhus and Typhus-like illnesses
WEEK
Cysticercosis or taeniasis WEEK Rocky Mountain Spotted Fever WEEK
Dengue Virus Infection
✆ !
Rubella (German Measles) WEEK
Diphtheria
✆ !
Rubella Syndrome, Congenital WEEK
Domoic Acid Poisoning (Amnesic
Shellfish Poisoning)
✆ !
Salmonellosis (Other than Typhoid
Fever)
FAX ✆ ✉
Ehrlichiosis WEEK Scombroid Fish Poisoning
✆ !
Encephalitis, Specify Etiology: Viral,
Bacterial, Fungal, Parasitic
FAX ✆ ✉
Shiga toxin (detected in feces)
✆ !
Escherichia coli: shiga toxin producing
(STEC) including E. coli O157
✆ !
Shigellosis
FAX ✆ ✉
Flavivirus infection of undetermined
species
✆ !
Smallpox(Variola)
✆ !
Foodborne Disease
† FAX ✆ ✉
Streptococcal Infections (Outbreaks of
Any Type and Individual Cases in Food
Handlers and Dairy Workers Only)
FAX ✆ ✉
Giardiasis WEEK Syphilis
FAX ✆ ✉
Gonococcal Infections WEEK Tetanus WEEK
Haemophilus influenzae, invasive
disease, all serotypes (report an
incident less than 5 years of age)
FAX ✆ ✉
Trichinosis
FAX ✆ ✉
Hantavirus Infections
FAX ✆ ✉
Tuberculosis
FAX ✆ ✉
Hemolytic Uremic Syndrome
✆ !
Tularemia, animal WEEK
Hepatitis A, acute infection
FAX ✆ ✉
Tularemia, human
✆ !
Hepatitis B (specify acute case or
chronic)
WEEK
Typhoid Fever, Cases and Carriers
FAX ✆ ✉
Hepatitis C (specify acute case or
chronic)
WEEK
Vibrio Infections
FAX ✆ ✉
Hepatitis D (Delta) (specify acute case
or chronic)
WEEK
Viral Hemorrhagic Fevers, human or
animal (e.g., Crimean-Congo, Ebola,
Lassa, and Marburg viruses)
✆ !
Hepatitis E, acute infection WEEK West Nile Virus (WNV) Infection
FAX ✆ ✉
Human Immunodeficiency Virus
(HIV) infection, stage 3 (AIDS)
WEEK
Yellow Fever
✆ !
Human Immunodeficiency Virus
(HIV), acute infection
✆
Yersiniosis
FAX ✆ ✉
CDPH 110a (03/18)
Page 4 of 4
Disease Name Urgency Disease Name Urgency
Influenza, deaths in laboratory-
confirmed cases for age 0-64 years
WEEK Zika Virus Infection
✆ !
Influenza, novel strains (human)
✆ !
OCCURRENCE of ANY UNUSUAL
DISEASE
✆ !
Legionellosis
WEEK
OUTBREAKS of ANY DISEASE
(Including diseases not listed in
§2500). Specify if institutional and/or
open community.
✆ !
Leprosy (Hansen Disease) WEEK
Leptospirosis WEEK
HIV REPORTING BY HEALTH CARE PROVIDERS §2641.30-2643.20
Human Immunodeficiency Virus (HIV) infection at all stages is reportable by traceable mail, person-to-person transfer,
or electronically within seven calendar days. For complete HIV-specific reporting requirements, see Title 17, CCR,
§2641.30-2643.20 and the California Department of Public Health’s HIV Surveillance and Case Reporting Resource
page (https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OA_case_surveillance_resources.aspx)
REPORTABLE NONCOMMUNICABLE DISEASES AND CONDITIONS §2800–2812 and §2593(b)
Disorders Characterized by Lapses of Consciousness
(§2800-2812) Pesticide-related illness or injury (known or suspected cases)**
Cancer, including benign and borderline brain tumors (except (1) basal and squamous skin cancer unless occurring on
genitalia, and (2) carcinoma in-situ and CIN III of the Cervix) (§2593)***
LOCALLY REPORTABLE DISEASES (If Applicable):
* This form is designed for health care providers to report those diseases mandated by Title 17, California Code of
Regulations (CCR). Failure to report is a misdemeanor (Health & Safety Code §120295) and is a citable offense under the
Medical Board of California Citation and Fine Program (Title 16, CCR, §1364.10 and 1364.11).
** Failure to report is a citable offense and subject to civil penalty ($250) (Health and Safety Code §105200).
*** The Confidential Physician Cancer Reporting Form may also be used. See Physician Reporting Requirements for
Cancer Reporting in CA at: www.ccrcal.org
CDPH 110a (03/18)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

CONFIDENTIAL MORBIDITY REPORT (HSA)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document