DISEASE BEING REPORTED
CONFIDENTIAL MORBIDITY REPORT
PLEASE NOTE: Only use this form for reporting Tuberculosis.
State of California—Health and Human Services Agency California Department of Public Health
Remarks:
CDPH 110b (07/16) (for reporting Tuberculosis)
TUBERCULOSIS (TB)
Status
Active Disease
Confirmed
Suspected
Infected, No Disease
Converter*
* For TST, an increase
of >10 mm in induration
size during <2 years.
Sites(s)
Pulmonary
Extra-Pulmonary
Both
Mantoux TB Skin Test
Date Placed
(mm/dd/yyyy)
Date Read
(mm/dd/yyyy)
Results: _______ mm
Not done
Pending
Not read
Interferon Gamma Release Assay (IGRA)
Date Collected: _______________
(mm/dd/yyyy)
Specify test name: _____________________
Results:
Positive
Indeterminate
Negative
Not done
Unknown
Imaging:
Chest X-Ray
Chest CT Scan or Other Chest
Imaging Study
Date Performed: _______________
(mm/dd/yyyy)
Results:
Normal
Pending
Cavitary
Abnormal/Noncavitary
Not done
Bacteriology/Pathology
Please mark positive on smear or culture if any
of initial specimens obtained was positive
Date Specimen Collected: _______________
(mm/dd/yyyy)
Source: _________________________________
Smear for acid-fast bacilli:
Pos Neg Pending Not done
Culture for M. tuberculosis complex:
Pos Neg Pending
Not done
Pathology suggests TB
Rapid Drug Resistance Assay
INH resistance
RIF resistance
No INH or RIF resistance detected
Not done
Nucleic Acid Amplification/PCR Test for
M. tuberculosis complex
Specify test type: _________________________
Results:
Pos
Neg
Indeterminate
Not done
Other test(s): ____________________________
Current Treatment (check all that apply)
INH RIF PZA
EMB
Other: ____________________
Other: ____________________
Other: ____________________
Date Treatment Initiated: ______________
(mm/dd/yyyy)
Drug resistance suspected
Untreated
Will treat
Unable to contact patient
Patient refused treatment
Referred to: _________________
Other: _____________________
TB TREATMENT INFORMATION
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: ______________
Page 1 of 2
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
