Fillable City and County of San Francisco San Francisco

Fill Online, Printable, Fillable, Blank City and County of San Francisco San Francisco Form

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

City and County of San Francisco San Francisco

On average this form takes 40 minutes to complete

The City and County of San Francisco San Francisco form is 2 pages long and contains:

  • 0 signatures
  • 171 check-boxes
  • 81 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS 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
 
*Potential Bioterrorism Agents effective July 2020
Title 17, California Code of Regulations (CCR) §2500, §2593, §2641.5-2643.20 and §2800-2812.
§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 conditions list
ed
bel
ow, to report to the local health officer for the jurisdiction where the patient resides. Where no health care provider is in attendance, any individual havi
ng
k
nowledge 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
out
break of disease within the facility shall establish and be responsible for administrative procedures to assure that reports are made to the local officer.
REPORT OUTBREAKS, DISEASES, AND CONDITIONS TO COMMUNICABLE DISEASE CONTROL UNIT UNLESS OTHERWISE INDICATED
COMMUNICABLE DISEASE CONTROL UNIT PHONE:
(415) 554-2830
FAX: (415) 554-2848 M-F 8AM TO 5PM
CD URGENT REPORTS: After hours: call
415-554-2830, press “2” & follow the instructions on the
voicemail to page the on-call MD.
HIV- New HIV cases must be called in to the
REPORTING PHONE: (628) 217-6335
ANIMAL CARE & CONTROL
ANIMAL BITES (MAMMALS Only)
PHONE: (415) 554-9422 FAX: (415) 864-2866
STD REPORTING
PHONE: (415) 487-5530 FAX: (415) 431-4628
ENVIRONMENTAL HEALTH SERVICES FOR
PESTICIDE
PHONE: (415) 252-3862 FAX: (415) 252-3818
COVID-19 REPORTING: CMR + LABs
Fax: (628) 217-7599
Secure Email: see other (CMR) side for instructions.
TUBERCULOSIS REPORTING
PHONE: (628) 206-8524 FAX: (628) 206-4565
URGENCY REPORTING KEY: ✆! Report immediately by telephone ✆ Report by phone within one working day of identification
❶ Report by electronic transmission (FAX), phone or mail within one working day of identification Report within seven calendar days by FAX, phone or mail
Anaplasmosis
❶
Haemophilus influenzae, invasive disease, all
✆!
Plague*, human or animal
Animal bites (mammals only) to Animal Care
serotypes (report an incident in persons
❶
Poliovirus infection
✆!
Anthrax*, human or animal
less than five years of age)
❶
Psittacosis
❶
Babesiosis
❶
Hantavirus infections
❶
Q Fever
✆!
Botulism* (Infant, Foodborne, Wound, Other)
✆!
Hemolytic Uremic Syndrome
✆!
Rabies, human or animal
Brucellosis, animal (except infections due to
❶
Hepatitis A, acute infection
❶
Relapsing Fever
Brucella canis)
Hepatitis B (specify acute, chronic or
Respiratory Syncytial Virus-associated
✆!
Brucellosis*, human
perinatal)
deaths in laboratory-confirmed cases less
❶
Campylobacteriosis
Hepatitis C (specify acute, chronic or
than five years of age
--
Cancer, including benign and borderline
perinatal)
Rickettsial Diseases (non-Rocky Mountain
brain tumors (except (1) basal and squamous skin
Hepatitis D (Delta) (specify acute or chronic)
Spotted Fever), including Typhus and
cancer unless occurring on genitalia, and (2) carcinoma in-
Hepatitis E, acute infection
Typhus-like Illnesses
situ and CIN III of the cervix) (Report w/in 30 days to
✆
Human Immunodeficiency Virus (HIV),
Rocky Mountain Spotted Fever
California Cancer Registry)
acute infection
Rubella (German Measles)
Chancroid to STD Reporting
Human Immunodeficiency Virus (HIV),
Rubella Syndrome, Congenital
❶
Chickenpox (Varicella) (outbreaks,
infection, any stage to HIV Reporting
❶
Salmonellosis (other than Typhoid Fever)
hospitalizations and deaths)
Human Immunodeficiency Virus (HIV)
✆!
Scombroid Fish Poisoning
❶
Chikungunya Virus Infection
infection, progression to stage 3 (AIDS)
✆!
Shiga toxin (detected in feces)
✆!
Cholera
to HIV reporting
❶
Shigellosis
✆!
Ciguatera Fish Poisoning
Influenza-associated deaths in laboratory-
✆!
Smallpox* (Variola)
Coccidioidomycosis
confirmed cases less than 18 years of age
❶
Syphilis (all stages, including congenital) to
✆!
Coronavirus Disease 2019 (COVID-19) to
✆!
Influenza, due to novel strains (human)
STD Reporting
COVID-19 Reporting
Legionellosis
Taeniasis
Creutzfeldt-Jakob Disease (CJD)
Leprosy (Hansen Disease)
Tetanus
❶
Cryptosporidiosis
Leptospirosis
Transmissible Spongiform Encephalopathies
Cyclosporiasis
❶
Listeriosis
(TSE)
Cysticercosis
Lyme Disease
❶
Trichinosis
❶
Dengue Virus Infection
❶
Malaria
❶
Tuberculosis to Tuberculosis Reporting
✆!
Diphtheria
✆!
Measles (Rubeola)
Tularemia, animal
Disorders Characterized by Lapses of
❶
Meningitis, Specify Etiology: Viral, Bacterial,
✆!
Tularemia*, human
Consciousness
Fungal, Parasitic
❶
Typhoid Fever (cases and carriers)
✆!
Domoic Acid Poisoning (Amnesic
✆!
Meningococcal infections
❶
Vibrio infections
Shellfish Poisoning)
✆!
Middle East Respiratory Syndrome (MERS)
✆!
Viral Hemorrhagic Fevers*, human or animal
Ehrlichiosis
Mumps
(e.g. Crimean-Congo, Ebola, Lassa and
❶
Encephalitis, Specify Etiology: Viral,
✆!
Novel Coronavirus Infection
Marburg viruses)
Bacterial, Fungal, Parasitic
✆!
Novel Virus Infection with Pandemic
❶
West Nile Virus (WNV) Infection
✆!
Escherichia coli: shiga toxin producing
Potential
❶
Yellow Fever
(STEC) including E. coli O157
✆!
Paralytic Shellfish Poisoning
❶
Yersiniosis
✆!
Flavivirus infection of undetermined species
❶
Paratyphoid Fever
❶
Zika Virus Infection
✆!
Foodborne illness (2 or more cases from
--
Parkinson's Disease,
Report w/in 90 days to
✆!
OCCURRENCE OF ANY UNUSUAL DISEASE
different households)
California Parkinson's Disease Registry (CPDR)
✆!
OUTBREAKS OF ANY DISEASE (including
Giardiasis
❶
Pertussis (Whooping Cough)
diseases not listed in §2500). Specify if
Gonococcal infections (including
Pesticide-related illness or injury (known or
institutional and/or open community.
disseminated) to STD Reporting
suspected cases) to Environmental Health
Services
For updates go to https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Public-Health-Reporting.aspx
REPORTABLE DISEASES AND CONDITIONS
City and County of San Francisco San Francisco Department of Public Health
WHOM TO REPORT TO:
DISEASE OR CONDITION/URGENCY REPORTING REQUIRMENTS [Title 17, CCR §2500 (h)(i)]
anti -HBc IgM
State of California—Health and Human Services Agency
Department of Public Health
CONFIDENTIAL MORBIDITY REPORT
NOTE:
For STD, Hepatitis, or TB, complete appropriate section below. Special reporting requirements and reportable diseases on back.
DISEASE BEING REPORTED: __________________________________________________________________________________
Social Security Number
Age
Address: Number, Street
Apt./Unit Number
City/Town
Gender (Please Check One)
Estimated Delivery Date
Month
Day
Year
Phone Number
Area Code
Primary Phone Number
Patient’s Occupation/Setting
❒
Other _________________________
DATE OF ONSET
Month Day Year
DATE DIAGNOSED
Month Day Year
City ZIP Code
DATE OF DEATH Telephone Number Fax
Month Day Year () ()
Submitted by Date Submitted
(Month/Day/Year)
SEXUALLY TRANSMITTED DISEASES (STD) Not
Syphilis Syphilis Test Results
RPR Titer:__________
VIRAL HEPATITIS
Pos Neg Pend Done
anti-HAV IgM
er: ________
Hep D (Delta)
anti-Delta
Other: ______________
Date Treatment Initiate
Suspected Exposure Type
Month Day Year
❒
Treated (Drugs, Dosage, Route):
_________________________
Blood
transfusion
Household
contact
_________________________
f
to:
Refered to:
_________________
Child care
Other: ________________________________
TUBERCULOSIS (TB) TB TREATMENT INFORMATION
Status
x TB Skin Test Bacteriology
Current Treatment
Month Day Year Month Day Year
I INH
EMB
RIF PZA
h
Other: ____________
Date Performed Date Specimen Collected Month Day Year
Infected, No Disease Pending Date Treatment
Results:______________ mm
Not Done Source _______________________________________ Initiated
Chest X-Ray Month Day Year
Will treat
Unable to contact patient
Refused treatment
Referred to: _____________________
REMARKS
–
Ethnicity ( one)
Hispanic/Latino
Non-Hispanic/Non-Latino
Race ( one)
African-American/Black
Asian/Pacific Islander ( one)
Japanese
Korean
Laotian
Samoan
Vietnamese
Asian-Indian
Cambodian
Chinese
Filipino
Guamanian
Hawaiian
Other_________
Native American/Alaskan Native
White
Other: __________________________
Unknown
VDRL
Hep B
HBsAg
FTA/M
Pos
❒
Ne
Neg
Acute
anti-HBc
Chronic
Other:_________________
of Sex Partners last 12 months
Hep C
anti -HCV
Acute
PCR-HCV
Chronic
State
ZIP Code
Male
Female
Trans Male
Trans Female
Unknown
Area Code Secondary Phone Number
–
–
–
Years
First Name/Middle Name (or initial)
Patient's Last Name
Month Day
Year
DOB
Country of Birth
Genderqueer/Gender Non-Binary
Please check all that apply:
Patient’s Last Name
First Name / Middle Name (or initial)
Address: Number, Street
City / Town
Social Security Number
DOB
Apt./Unit Number
Phone Number
Age
MONTH DAY YEAR
State
Male
Female
Trans Male
Trans Female
Unknown
Food service
Other
Patient’s Occupation/Setting
Area Code Secondary Phone Number
Area Code Primary Phone Number
Pregnant?
Estimated Delivery Date:
Gender (Please Check One)
Reporting Health Care Provider
Medical Record Number
Reporting Health Care Facility
Address
City
State
ZIP Code
Telephone Number
Fax
Submitted by
Latent (unknown duration)
Chlamydia
G
onorrhea
Treated (Drugs, Dosage, Route):
Syphilis Test Results
RPR
VD
RL
CS
F-VDRL
TP-
PA
EIA/CLIA
Titer:
Titer:
P
os
Date Submitted
Genderqueer/Gender Non-Binary
Not Listed (Specify):
ZIP Code Country of Birth
On PrEP for HIV prevention Y
N
UNK
TUBERCULOSIS (TB)
Status
Active Disease
Site(s)
Pulmonary
Chest X-Ray
TB Testing
IGRA
PPD/TST
Date Performed
Results:
REMARKS
Date Specimen Collected
Accession number
Source:
Smear:
Pathology suggests TB
Other test(s) ___________________________________
Month
Month
Month
Day
Day
Day
Year
Year
Year
Year
Bacteriology/Pathology
NAAT/PCR
Positive
Negative
Treated in office
Unable to contact patient
Refused treatment
Referred to:
Given prescription
Month Day Year
Neurosyphilis
Ocular Syphilis Y N UNK
Other:
R
eport all non-STD, non-TB, non-HIV to:
Communicable Disease Control Unit
San Francisco Dept. of Public Health
25 Van Ness Ave, Suite 500, SF CA 94102
CD Phone: (415) 554-2830
CD Fax: (415) 554-2848
COVID-19 Fax: (628)217-7599
Email: include ‘SECURE’ in subject line: send to
both cdcontrol@sfdph.org and trace@sfdph.org
STD Fax: (415) 431-4628
TB Fax: (628) 206-4565
HIV: Phone reports only: (628) 217-6335
Gender(s) of Sex Partners last 12 months
Please check all that apply:
anti -HBs
DD MM YY
Specimen Source
Urine
Y N
UNK
Day care
Health care
School
Correctional facility
P
os
Neg
P
os
Neg
Neg
Late latent > 1 year
Congenital
Late (tertiary)
LTBI
Suspected
Date Performed
Normal
Attach all results to CMR
Pos Neg Pending
Culture
:
Pos Neg Pending
Other needle
exposure
Sexual
contact
Untreated
LGV
Pharyngeal
Rectal
Urethral/Cervical
Vaginal
Other:
PM 110 (SF 11/2020)
Hep A
Male Female Trans Male Trans Female
Unknown Genderqueer/Gender Non-Binary
(Suspect)
Confirmed
Cavitary
Abnormal/Noncavitary
Early latent <1year
Secondary
Primary (lesion present)
Y
N
UNK
Extra-Pulmonary
RIF resistance detected
RIF resistance NOT
detected
STD TREATMENT INFORMATION
Unknown
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

City and County of San Francisco San Francisco

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 8 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document