Form Cdph 110A PDF Details

In the complex landscape of public health reporting and management, the CDPH 110A form emerges as a critical document within California's healthcare infrastructure. Designed and mandated by the State of California—Health and Human Services Agency, and specifically utilized by the California Department of Public Health, this form assumes a vital role in the confidential morbidity reporting process. It stipulates a structured approach for healthcare professionals to report a wide spectrum of conditions, excluding Tuberculosis and conditions reportable to the Department of Motor Vehicles (DMV). The comprehensive nature of the form captures detailed patient information including but not limited to ethnicity, race, gender, birth details, contact information, and linguistic preference. Significantly, the form delves into specifics regarding the disease being reported, exposure settings, onset and diagnosis dates, and detailed treatment information for sexually transmitted diseases (STDs), as well as viral hepatitis—highlighting its pivotal role in disease surveillance and public health initiative. Equally important is the section dedicated to the reporting healthcare provider and facility, ensuring a clear channel for communication and follow-up. This intricate form not only facilitates a systematic reporting to health authorities but also underscores the importance of accurate data collection in implementing effective public health strategies and interventions.

QuestionAnswer
Form NameForm Cdph 110A
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesCMRcdph0110a confidential morbidity report san bernardino county form

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 all conditions except Tuberculosis and conditions reportable to DMV.

DISEASE 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

 

 

 

 

 

 

 

 

 

 

 

 

English

Spanish

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary

 

 

 

 

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): ________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Days

 

 

Female

 

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)

 

Date of Death (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.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Laboratory Name

City

State

ZIP Code

SEXUALLY TRANSMITTED DISEASES (STDs)

Gender of Sex Partners

(check all that apply)

Male

M to F Transgender

Female

F to M Transgender

Unknown

Other: __________

STD TREATMENT

 

Treated in office

Given prescription

Treatment Began

 

 

Untreated

Drug(s), Dosage, Route

 

 

 

 

Will treat

 

 

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

Unable to contact patient

Patient refused treatment

Referred to: ____________

If reporting Syphilis, Stage:

Primary (lesion present) Secondary

Early latent < 1 year Latent (unknown duration)

Late latent > 1 year

Late (tertiary)

Congenital

Neurosyphilis?

Yes No Unknown

Syphilis Test Results

 

 

Titer

RPR

 

 

Pos

Neg

_____

 

VDRL

Pos

Neg

_____

FTA-ABS

Pos

Neg

 

TP-PA

Pos

Neg

 

EIA/CLIA

Pos

Neg

 

CSF-VDRL

Pos

Neg

_____

Other: ____________________

If reporting Chlamydia and/or Gonorrhea:

If reporting Pelvic Inflammatory Disease:

Specimen Source(s)

 

Symptoms?

 

 

 

(check all that apply)

(check all that apply)

 

 

 

 

Yes

 

 

Gonococcal PID

 

 

 

 

Cervical

 

 

 

 

No

 

 

Chlamydial PID

 

 

 

 

 

 

 

 

 

 

Pharyngeal

 

 

 

 

 

 

 

 

 

 

 

 

Unknown

 

 

Other/Unknown Etiology PID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rectal

 

 

 

 

 

 

 

 

 

 

 

 

 

Partner(s) Treated?

 

 

 

No, instructed patient to

 

 

Urethral

 

 

 

 

 

 

 

 

Yes, treated in this clinic

refer partner(s) for

 

 

 

 

 

 

 

 

Urine

 

 

 

treatment

 

 

 

 

 

Yes, Meds/Prescription given

 

 

Vaginal

 

 

 

No, referred partner(s) to:

 

 

 

 

 

 

to patient for their partner(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other: _________

 

 

 

Yes, other: ______________

 

 

 

 

 

 

 

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VIRAL HEPATITIS

Diagnosis (check all that apply)

Hepatitis A

Hepatitis B (acute)

Hepatitis B (chronic)

Hepatitis B (perinatal)

Hepatitis C (acute)

Hepatitis C (chronic)

Hepatitis D

Hepatitis E

 

 

Is patient symptomatic?

Yes

No

Unknown

Suspected Exposure Type(s)

 

 

 

 

 

Blood transfusion, dental or

ALT (SGPT)

 

 

 

 

 

 

medical procedure

 

 

Upper

 

 

 

 

 

 

 

 

 

 

 

IV drug use

Result: _____

Limit: _____

 

 

Other needle exposure

 

 

 

 

 

Sexual contact

AST (SGOT)

 

 

 

 

 

Upper

 

 

Household contact

 

 

 

 

Result: _____

Limit: _____

 

 

 

 

 

Perinatal

 

 

 

 

 

Child care

Bilirubin result: ____________

 

 

 

 

 

Other: _______________

 

 

 

 

 

 

 

 

 

 

Pos

Neg

 

Pos Neg

 

 

 

 

 

 

 

Hep A

anti-HAV IgM

 

Hep C

anti-HCV

Hep B

HBsAg

 

 

 

 

RIBA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HCV RNA

 

anti-HBc total

 

 

 

 

 

(e.g., PCR)

 

anti-HBc IgM

 

 

 

 

 

 

 

 

 

anti-HBs

 

Hep D

anti-HDV

 

HBeAg

 

Hep E

anti-HEV

 

anti-HBe

 

 

 

 

 

 

 

 

HBV DNA: ___________

 

 

 

 

 

 

 

 

 

 

 

 

 

Remarks:

CDPH 110a (1/11) (for reporting all conditions except Tuberculosis and conditions reportable to DMV)

Page 1 of 2

State of California—Health and Human Services Agency

California Department of Public Health

CDPH 110a (1/11)

Page 2 of 2