California Form Pm110 PDF Details

In California, the health and safety of the public are paramount, with various mechanisms in place for monitoring and managing communicable and noncommunicable diseases. The Confidential Morbidity Report, known as form PM110, serves as a critical tool in this endeavor. Designed by the State of California Health and Human Services Agency Department of Public Health, this form facilitates the reporting of diseases and conditions specified under Title 17 of the California Code of Regulations (CCR). Health care providers, upon identification of a case or suspected case of listed diseases, are mandated to report to the local health officer within specified timeframes, thereby enabling timely intervention and prevention of further spread. The form encompasses a range of diseases, from STDs and viral hepatitis to tuberculosis, requiring detailed information on diagnosis, onset, and patient demographics, to effectively track and manage public health threats. Moreover, the form also delineates urgent reporting requirements, reinforcing the importance of prompt communication with public health authorities in addressing outbreaks or unusual occurrences of diseases. Thus, the PM110 form embodies an essential aspect of California's public health strategy, emphasizing collaboration among health care providers and public health officials in safeguarding community health.

QuestionAnswer
Form NameCalifornia Form Pm110
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespm110 california morbidity report online form

Form Preview Example

State of California—Health and Human Services AgencyDEpartment of Public Health

CONFIDENTIAL MORBIDITY REPORT

NOTE: For STD, Hepatitis, or TB, complete appropriate section below. Special reporting requirements and reportable diseases onback.

DISEASE BEING REPORTED:___________________________________________________________________________________

Patient’s Last Name

Social Security Number

Ethnicity (one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hispanic/Latino

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Non-Hispanic/Non-Latino

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Age

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name/Middle Name (or initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race (one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

Day

 

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

African-American/Black

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Asian/Pacific Islander (one):

 

 

 

Address: Number, Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apt./Unit Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Asian-Indian

Japanese

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cambodian

Korean

 

 

 

City/Town

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chinese

Laotian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Filipino

Samoan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Guamanian

Vietnamese

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Estimated Delivery Date

 

 

 

 

Area Code

Home Telephone

 

 

 

 

 

Gender

Pregnant?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

Day

Year

 

 

 

 

Hawaiian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

F

 

 

 

Y

 

N

 

 

Unk

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Native American/Alaskan Native

 

 

 

Area Code

Work Telephone

 

 

 

 

Patient’s Occupation/Setting

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

White: __________________________

 

 

 

 

 

 

 

 

 

 

 

 

Food service

 

 

Day care

 

Correctional facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health care

 

 

School

 

Other _________________________

 

Other: __________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF ONSET

Reporting Health Care Provider

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REPORT TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reporting Health Care Facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE DIAGNOSED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

 

 

 

 

 

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF DEATH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

Fax

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

Day

Year

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Submitted by

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Submitted

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Day/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Obtain additional forms from your local health department.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SEXUALLY TRANSMITTED DISEASES (STD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VIRAL HEPATITIS

 

 

 

 

 

 

Not

Syphilis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Syphilis Test Results

 

 

 

 

 

 

 

Hep A

 

 

 

 

 

Pos

Neg

Pend

Done

Primary (lesion present)

 

 

 

Late latent > 1 year

RPR

 

 

 

 

Titer:__________

 

 

 

 

 

anti-HAV IgM

Secondary

 

 

 

 

 

 

Late (tertiary)

 

 

 

 

VDRL

 

 

 

 

Titer:__________

 

Hep B

 

 

 

HBsAg

Early latent < 1 year

 

 

 

Congenital

 

 

 

 

FTA/MHA:

Pos

 

Neg

 

 

 

Acute

 

 

 

anti-HBc

Latent (unknown duration)

 

 

 

 

 

 

 

 

 

 

 

 

 

CSF-VDRL:

Pos

 

Neg

 

 

 

Chronic

 

 

 

anti-HBc IgM

Neurosyphilis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:_________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

anti-HBs

Gonorrhea

 

 

 

 

 

Chlamydia

 

 

 

 

 

 

 

 

PID (Unknown Etiology)

 

 

 

 

Hep C

 

 

 

anti-HCV

Urethral/Cervical

 

 

 

Urethral/Cervical

 

 

 

 

 

 

 

 

 

Acute

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chancroid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PCR-HCV

PID

 

 

 

 

 

 

 

 

PID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chronic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Non-Gonococcal Urethritis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other: ____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other: _____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hep D (Delta)

anti-Delta

STD TREATMENT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

Untreated

 

 

 

 

 

 

 

 

 

 

 

 

 

Other: ______________

Treated(Drugs,Dosage,Route):

 

Date Treatment Initiated

Will treat

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Suspected Exposure Type

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unable to contact patient

 

 

 

 

 

 

 

 

 

 

 

 

 

____________________________

Month

Day

Year

 

 

 

 

Blood

Other needle

Sexual

Household

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Refused treatment

 

 

 

 

 

 

 

 

 

 

 

transfusion

 

exposure

contact

contact

____________________________

 

 

 

 

 

 

 

 

 

 

 

 

Referred to:_________________

 

Child care

Other: ________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TUBERCULOSIS (TB)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TB TREATMENT INFORMATION

Status

 

 

 

 

 

Mantoux TB Skin Test

 

 

 

 

 

 

Bacteriology

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Treatment

 

 

 

 

 

Active Disease

 

 

 

 

 

Month

 

 

Day

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month Day

 

 

Year

 

 

 

 

INH

 

RIF

PZA

Confirmed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMB

 

Other:____________

Suspected

 

 

 

Date Performed

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Specimen Collected

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

Day

Year

Infected, No Disease

 

 

 

 

 

 

 

 

 

Pending

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Treatment

 

 

 

 

 

 

 

 

Convertor

 

 

 

Results:______________ mm Not Done

 

 

Source _______________________________________

 

Initiated

 

 

 

 

 

 

 

 

 

Reactor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Smear:

 

 

Pos

Neg

Pending

Not done

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chest X-Ray Month

 

 

Day

 

Year

 

 

Culture:

 

 

Pos

Neg

Pending

Not done

 

Untreated

 

 

 

 

 

 

 

Site(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Will treat

 

 

 

 

 

 

 

Pulmonary

 

 

 

Date Performed

 

 

 

 

 

 

 

 

 

 

 

 

 

Other test(s) ___________________________________

 

 

Unable to contact patient

 

 

 

Extra-Pulmonary

 

Normal

Pending Not done

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Refused treatment

 

 

 

 

 

Both

 

 

 

 

 

Cavitary

Abnormal/Noncavitary

 

_______________________________________

 

 

Referred to:_____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REMARKS

PM 110 (revised 12/08/09)

page 1 of 2

State of Califonria - Health and Human Sevices AgencyDepartment of Public Health

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 juridiction 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)]

✆ ✆

FAX ✆ ✉

=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 electronic transmission (including FAX), telephone, or mail within one working day of identification (designated by a + in regulations).

=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)

FAX

FAX

FAX

FAX

FAX

FAX

FAX

FAX

FAX

FAX

FAX

FAX

FAX

FAX

FAX

Acquired Immune Deficiency Syndrome (AIDS)

(HIV infection only: see "Human Immunodeficiency Virus") ✆ ✉ Amebiasis

Anaplasmosis/Ehrlichiosis ✆ ✆ Anthrax

✆ ✆ Avian Influenza (human) ✆ ✉ Babesiosis

✆ ✆ Botulism (Infant, Foodborne, Wound) ✆ ✆ Brucellosis

✆ ✉ Campylobacteriosis

Chancroid

✆ ✉ Chickenpox (only hospitalizations and deaths)

Chlamydia trachomatis infections, including Lymphogranuloma Venereum (LGV) ✆ ✆ Cholera

✆ ✆ Ciguatera Fish Poisoning

Coccidioidomycosis ✆ ✉ Colorado Tick Fever

Creutzfeldt-Jakob Disease (CJD) and other Transmissible Spongiform Encephalopathies (TSE)

✆ ✉ Cryptosporidiosis Cysticercosis or Taeniasis

✆ ✆ Dengue

✆ ✆ Diphtheria

✆ ✆ Domoic Acid Poisoning (Amnesic Shellfish Poisoning)

✆ ✉ Encephalitis, Specify Etiology: Viral, Bacterial, Fungal, Parasitic

✆ ✆ Escherichia coli : shiga toxin producing (STEC) including E. coli O157 ✆ ✉ Foodborne Disease

Giardiasis Gonococcal Infections

✆ ✉ Haemophilus influenzae invasive disease (report an incident less than 15 years of age)

✆ ✆ Hantavirus Infections

✆ ✆ Hemolytic Uremic Syndrome Hepatitis, Viral

✆ ✉ Hepatitis A

Hepatitis B (specify acute case or chronic) Hepatitis C (specify acute case or chronic) Hepatitis D (Delta)

Hepatitis, other, acute

Influenza deaths (report an incident of less than 18 years of age) Kawasaki Syndrome (Mucocutaneous Lymph Node Syndrome) Legionellosis

Leprosy (Hansen Disease) Leptospirosis

✆ ✉ Listeriosis Lyme Disease

✆ ✉ Malaria

✆ ✉ Measles (Rubeola)

✆ ✉ Meningitis, Specify Etiology: Viral, Bacterial, Fungal, Parasitic

✆ ✆ Meningococcal Infections Mumps

✆ ✆ Paralytic Shellfish Poisoning Pelvic Inflammatory Disease (PID)

✆ ✉ Pertussis (Whooping Cough) ✆ ✆ Plague, Human or Animal

FAX

✆ ✉

Poliovirus Infection

FAX

✆ ✉

Psittacosis

FAX

✆ ✉

Q Fever

 

✆ ✆

Rabies, Human or Animal

FAX

✆ ✉

Relapsing Fever

 

 

Rheumatic Fever, Acute

 

 

Rocky Mountain Spotted Fever

 

 

Rubella (German Measles)

 

 

Rubella Syndrome, Congenital

FAX

✆ ✉

Salmonellosis (Other than Typhoid Fever)

 

✆ ✆

Scombroid Fish Poisoning

 

✆ ✆

Severe Acute Respiratory Syndrome (SARS)

 

✆ ✆

Shiga toxin (detected in feces)

FAX

✆ ✉

Shigellosis

 

✆ ✆

Smallpox (Variola)

FAX

✆ ✉

Staphylococcus aureus infection (only a case resulting in death or admission to an

 

 

intensive care unit of a person who has not been hospitalized or had surgery, dialysis,

 

 

or residency in a long-term care facility in the past year, and did not have an indwelling

 

 

catheter or percutaneous medical device at the time of culture)

FAX

✆ ✉

Streptococcal Infections (Outbreaks of Any Type and Individual Cases in Food

 

 

Handlers and Dairy Workers Only)

FAX

✆ ✉

Syphilis

 

 

Tetanus

 

 

Toxic Shock Syndrome

FAX

✆ ✉

Trichinosis

FAX

✆ ✉

Tuberculosis

 

✆ ✆

Tularemia

FAX

✆ ✉

Typhoid Fever, Cases and Carriers

 

 

Typhus Fever

FAX

✆ ✉

Vibrio Infections

 

✆ ✆

Viral Hemorrhagic Fevers (e.g., Crimean-Congo, Ebola, Lassa, and Marburg viruses)

FAX

✆ ✉

Water-Associated Disease (e.g., Swimmer's Itch or Hot Tub Rash)

FAX

✆ ✉

West Nile Virus (WNV) Infection

 

✆ ✆

Yellow Fever

FAX

✆ ✉

Yersiniosis

 

✆ ✆

OCCURRENCE of ANY UNUSUAL DISEASE

 

✆ ✆

OUTBREAKS of ANY DISEASE (Including diseases not listed in§2500). Specify if

 

 

institutional and/or open community.

HIV REPORTING BY HEALTH CARE PROVIDERS §2641.5-2643.20

Human Immunodeficiency Virus (HIV) infection is reportable by traceable mail or person-to-person transfer within seven calendar days by completion of the HIV/AIDS Case Report form (CDPH 8641A) available from the local health department. For completing HIV-specific reporting requirements, see Title 17, CCR, §2641.5-2643.20 and http://www.cdph.ca.gov/programs/aids/Pages/OAHIVReporting.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 (Heatlh and 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.

PM110 (revised 12/08/09)

page 2 of 2

How to Edit California Form Pm110 Online for Free

If you need to fill out California Form Pm110, you won't need to download and install any software - simply try using our PDF editor. To keep our editor on the leading edge of convenience, we work to put into practice user-oriented capabilities and enhancements regularly. We're always looking for suggestions - play a vital part in reshaping PDF editing. It just takes just a few basic steps:

Step 1: Click on the "Get Form" button above. It will open up our tool so you could begin filling in your form.

Step 2: Using our advanced PDF editor, you could accomplish more than simply complete blank form fields. Edit away and make your forms seem high-quality with customized textual content put in, or modify the original input to excellence - all backed up by an ability to insert stunning photos and sign the document off.

When it comes to blank fields of this particular PDF, this is what you need to know:

1. While completing the California Form Pm110, make sure to incorporate all needed blanks in their relevant part. This will help to facilitate the process, allowing for your information to be handled without delay and correctly.

California Form Pm110 conclusion process shown (stage 1)

2. Soon after completing the previous part, go on to the subsequent step and fill in the essential details in these blank fields - DATE OF DEATH, Month, Day, Year, Telephone Number , Submitted by, SEXUALLY TRANSMITTED DISEASES STD, Primary lesion present Secondary, Neurosyphilis, Gonorrhea, UrethralCervical PID Other , Late latent year Late tertiary, Chlamydia, Fax , and Date Submitted.

 Neurosyphilis, Gonorrhea, and  Late latent   year  Late tertiary of California Form Pm110

3. This step is normally straightforward - fill in every one of the empty fields in Infected No Disease, Pending, Convertor Reactor, Sites Pulmonary ExtraPulmonary , REMARKS, Results mm Not Done Source Smear, Chest XRay, Month, Day, Year, Date Performed, Normal Pending Not done , Other tests , Date Treatment, and Initiated to finish the current step.

Writing segment 3 of California Form Pm110

Be extremely attentive while filling in Results mm Not Done Source Smear and Day, since this is the part where most people make some mistakes.

4. This next section requires some additional information. Ensure you complete all the necessary fields - Mumps, Paralytic Shellfish Poisoning, Pelvic Inflammatory Disease PID, FAX Pertussis Whooping Cough, Plague Human or Animal, LOCALLY REPORTABLE DISEASES If, This form is designed for health, and is a citable offense under, Failure to report is a citable, and PM revised page of - to proceed further in your process!

Completing segment 4 of California Form Pm110

Step 3: Ensure that the information is correct and just click "Done" to proceed further. After getting afree trial account with us, you will be able to download California Form Pm110 or send it through email at once. The PDF form will also be available through your personal account page with all your adjustments. We don't share any information that you use whenever working with documents at our website.