State of California—Health and Human Services Agency California Department of Public Health
CONFIDENTIAL MORBIDITY REPORT
PLEASE NOTE: Only use this form for reporting COVID-19. Report to local health department within one working day.
DISEASE BEING REPORTED: COVID-19
Ethnicity (check one)
Hispanic/Latino Non-Hispanic/Non-Latino Unknown
Race (check all that apply)
African-American/Black
American Indian/Alaska Native
Asian (check all that apply)
Asian Indian Hmong Thai
Cambodian Japanese Vietnamese
Chinese Korean Other (specify):
Filipino Laotian
Pacific Islander (check all that apply)
Native Hawaiian Samoan
Other (specify):
Guamanian
White
Other (specify):
Home Address: Number, Street
Primary
Language
Gender:
M to F
Male
Female
F to M
Pregnant?
Yes
No Unknown
EDD
Occupation or Job Title:
Country of Birth
Congregate setting (check if applies)
Date of Death
(
if applies)
Reporting Health Care Facility
(Obtain additional forms from your local health department.)
Address: Number, Street Suite/Unit No.
City State ZIP Code
Telephone Number Fax Number
Email Address:
Date Submitted
City State ZIP Code
COVID-19: Hospitalization Status and Diagnostic Testing Clinical Information
Status at Time of Report
Clinical or Radiologic
Evidence of Pneumonia
(check all that apply)
COVID-19 Testing (Complete all that apply)
Positive
Result:
Indeterminate
Pending
Chest X-Ray
Chest CT Scan
Other Chest Imaging Study
COVID-19 Symptoms (Check all that apply)
CDPH 110d (04/20) (for reporting COVID-19) Page 1 of 1
Hospitalized, ICU
Hospitalized, non-ICU
Not Hospitalized
Deceased
Intubated
Not Intubated
PCR swab (NP and/or OP)
Negative
Date Performed
Clinical or Radiologic
Evidence of ARDS
(check all that apply)
None
Clinical
Radiologic
Close contact with a laboratory confirmed COVID-19 case?
None
Clinical
Radiologic
Date Hospitalized
(if ever hospitalized)
Complete
dates
where applies
Date Intubated
(if ever intubated)
Chronic Conditions (Check all that apply)
None Unknown
Cardiovasc. disease
Hypertension
Chronic kidney disease
Neurological/
neuro-developemental
Diabetes
Asthma
Chronic liver disease
Obesity
Yes (specify):
No
Other (specify):
Date of first symptom onset
No
Yes
No
Yes
No
Yes
Status History
Ever Hospitalized?
Ever in ICU?
Ever Intubated?
Ever Placed on ECMO?
Yes
Positive
Result:
Indeterminate
PendingNegative
No
Respiratory Complications
Date Performed
Date Performed
Imaging performed (check all that apply)
Positive
Result:
Indeterminate
Pending
Other___________________________
Negative
Date InitiatedDrug, Dosage, Route
Date InitiatedDrug, Dosage, Route
Serology Test Name ____________
Please write all dates as (mm/dd/yyyy)
Shelter
Unknown
Reporting Health Care Provider
Yes No Unknown
Household contact
Community contact
Any healthcare contact
Workplace contact
Stable
Unstable
Unknown
Housing Status
None
Chills
Sore throat
Difficulty breathing
Loss of smell
Vomiting
Fever >100.4F, 38C
Rigors
Cough
Muscle aches
Loss of taste
Abdominal pain
Subjective fever
Runny nose
Shortness of Breath
Headache
Nausea
Diarrhea
Cancer
Current smoker
Yes No
Unknown
If yes, location(s):
Other diagnosis or etiology for respiratory condition?
Date Discharged
(if previously hospitalized)
Healthcare Worker
Name,City of Congregate Setting(s) (if applies):
COVID-19 Specific Treatment (s)
Additional Remarks
Clinic
Date InitiatedDrug, Dosage, Route
Chronic lung disease
Stroke
Immunocompromised
Former smoker
Other (specify):
Current e-cigarette or vape use
Additional Contact Details (if applies)
Not tested for COVID-19
Staff Resident Unknown
Skilled Nursing Facility
Hospital-Based Facility
Assisted Living Facility
Correctional Facility
Other (specify)
Travel to or reside in an area with sustained, ongoing, community
transmission of SARS-CoV-2?
Thromboses (e.g. stroke, DVT, PE)
Dermatologic finding
Diagnosis Date:
In Healthcare Setting
What is the patient's sexual orientation?
Gay/Lesbian/Homosexual
Heterosexual
Bisexual
Other Unknown
Other:
M to F
Male
Female
F to M
Unknown
Declined to state
Gender(s) of sex partners (check all that apply):
Declined
to state
Contra Costa Public Health
Communicable Disease Programs
597 Center Ave.
Martinez, CA 94553 *Please complete as fully
as you can and ensure
Phone: 925-313-6740 Sensitive Occupations
Fax: 925-313-6465 and Settings (SOS) fields
cchealth.org (highlighted) are complete
