Confidential Morbidity Report Form PDF Details

The Confidential Morbidity Report Form (CMRF) is a document used to report morbidity in hospitals, long-term care facilities, and other healthcare settings. The CMRF is also used to track the spread of disease and monitor outbreaks. The form is filled out by hospital staff or healthcare providers, who then submit it to their local health department. The information collected on the CMRF can be used to improve public health planning and response to outbreaks.

QuestionAnswer
Form NameConfidential Morbidity Report Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesconfidential morbidity report dmv, california, 110c, Alaska

Form Preview Example

State of California—Health and Human Services Agency

California Department of Public Health

CONFIDENTIAL MORBIDITY REPORT

PLEASE NOTE: Use this form for reporting lapses of consciousness or control, Alzheimer's disease or other conditions which may impair the ability to operate a motor vehicle safely (pursuant to H&S 103900).

CONDITION BEING REPORTED

Patient Name - Last Name

 

 

 

 

 

 

First Name

 

 

 

 

 

 

 

 

 

 

 

 

MI

Ethnicity (check one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hispanic/Latino

Non-Hispanic/Non-Latino

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race (check all that apply)

 

 

 

 

 

 

 

 

 

 

Home Address: Number, Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apt./Unit No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

African-American/Black

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

American Indian/Alaska Native

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Asian (check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Asian Indian

 

Hmong

Thai

 

 

 

 

Home Telephone Number

 

Cell Telephone Number

 

 

 

 

Work Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cambodian

 

Japanese

Vietnamese

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chinese

 

 

 

 

Korean

Other (specify):

Email Address

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary

 

 

English

Spanish

 

 

 

 

Filipino

 

 

 

 

Laotian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Language

Other: ______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pacific Islander

(check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth Date (mm/dd/yyyy)

Age

 

 

Years

Gender

 

M to F Transgender

 

 

 

 

Native Hawaiian

Samoan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Months

 

 

 

Male

 

F to M Transgender

 

 

 

 

Guamanian

 

Other (specify): ________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Days

 

 

 

 

Other: ____________

 

 

 

White

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pregnant?

 

 

 

Est. Delivery Date (mm/dd/yyyy)

Country of Birth

 

 

 

 

 

 

 

 

 

 

 

Other (specify): _______________

 

 

 

 

 

 

 

 

 

Yes

No

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Occupation or Job Title

 

 

 

 

 

 

 

 

 

 

 

 

Occupational or Exposure Setting (check all that apply):

 

 

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)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reporting Health Care Provider

 

 

 

 

 

Reporting Health Care Facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REPORT TO:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address: Number, Street

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Suite/Unit No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

 

 

 

 

 

Fax Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Submitted by

 

 

 

 

 

 

 

 

 

 

 

 

Date Submitted (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Obtain additional forms from your local health department.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPARTMENT OF MOTOR VEHICLES (DMV)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

California Driver License or Identification Card Number (eight characters):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

If this report is based upon episodic lapses of consciousness, when was the most recent episode?: _______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

2.

 

If there have been multiple episodes of loss of consciousness or control within the past three years, please indicate the dates if they are known to you.

 

 

 

(a):

 

 

 

 

(b):

 

 

 

 

 

 

(c):

 

 

 

 

 

 

 

 

 

 

 

(d):

 

 

 

 

 

 

 

 

 

 

(e):

 

 

 

 

 

 

 

(f):

 

 

 

 

 

 

 

 

 

 

 

 

(mm/dd/yyyy)

 

 

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

(mm/dd/yyyy)

 

 

 

 

 

(mm/dd/yyyy)

(mm/dd/yyyy)

 

 

 

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

 

Within the past 12 months, has there been an episode of loss of consciousness or control while driving?

 

 

 

Yes

No

 

 

Uncertain

 

 

 

 

 

 

4.

 

Are additional lapses of consciousness likely to occur?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

Uncertain

 

 

 

 

 

 

5.

 

If the patient has had episodes of nocturnal seizures, is there likelihood of lapses of consciousness

Yes

No

 

 

Uncertain

 

 

 

 

 

 

 

 

 

occurring while he/she is awake?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

 

Has this patient been diagnosed with dementia or Alzheimer's disease?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

Uncertain

 

 

 

 

 

 

7.

 

Would you currently advise this patient not to drive because of his/her medical condition?

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

Uncertain

 

 

 

 

 

 

8.

 

Does this patient's condition represent a permanent driving disability?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

Uncertain

 

 

 

 

 

 

9.

 

Would you recommend a driving evaluation by DMV?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

Uncertain

 

 

 

 

 

 

Remarks:

CDPH 110c (10/11) (for reporting conditions reportable to DMV)

Page 1 of 2

State of California—Health and Human Services Agency

California Department of Public Health

CDPH 110c (10/11)

Page 2 of 2

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3. The following part is mostly about If the patient has had episodes, Has this patient been diagnosed, Would you currently advise this, Does this patients condition, Would you recommend a driving, Yes, Yes, Yes, Yes, Uncertain, Uncertain, Uncertain, Uncertain, Remarks, and CDPH c for reporting conditions - complete every one of these blank fields.

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