State of California—Health and Human Services Agency California Department of Public Health
Surveillance and Statistics Section
P.O. Box 997377, MS 7306
Sacramento, CA 95899-7377
U OTHER OUTBREAK (Use CDC 52.12 for waterborne disease outbreaks; CDC 52.13 for foodborne disease outbreaks.)
U OTHER REPORTABLE DISEASE OR DISEASE OF UNUSUAL OCCURRENCE
U
Confirmed U Not confirmed U Suspected
Kind of outbreak/illness
PERSONAL DATA—FOR SINGLE CASE ONLY
Patient name–last first middle initial Date of birth Age Sex
Address–number, street City State County ZIP code
RACE (check one) ETHNICITY (check one)
U African-American/Black U White U Native American U Asian/Pacific Islander U Other ____________________ U Hispanic/Latino U Non-Hispanic/Non-Latino
If Asian/Pacific Islander, please check one: U Asian Indian U Cambodian U Chinese U Filipino U Guamanian U Hawaiian
U Japanese U Korean U Laotian U Samoan U Vietnamese U Other________________
LOCATION AND SCOPE OF OUTBREAK—FOR OUTBREAK ONLY
City County Name of community, camp, or institution
Population at risk Number of persons investigated Number of persons ill Number of cases laboratory Number hospitalized Number of deaths
epidemiologically confirmed
Date of Onset Number of
Under 1 year 1–4 years 5–9 years 10–19 years 20–39 years 40–59 years 60 and over
persons ill by
First case: Last case: age group
REASON FOR INVESTIGATION
Was the California Department of Public Health notified? U Yes U No
HISTORY OF ILLNESS
Brief description of clinical course and the characteristics of the epidemic or case. Include date of onset and hospitalization for case.
Incubation period (range in hours or days) Average duration of symptoms Outcome of case
Minimum: Maximum: U Recovered U Fatal Date of death _______________________
DIAGNOSTIC TESTS
SPECIMENS TYPE RESULTS
Number of
DATE OF
Number
Type Patients COLLECTED TEST Positive Etiology NAME AND ADDRESS OF LABORATORY
RESULTS OF INVESTIGATION AND REMARKS
Summary of investigation, giving probable source with sustaining evidence; also name and address of suspected carrier or missed cases.
CDPH 8554 (07/07) (This replaces 10/03 version.)
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