Form Cdph 110A PDF Details

CDPH Form 110A is a document that is used to report the number of employees who work in a food establishment. This form must be completed by food establishments every year, and must include the total number of employees who worked at the establishment during the calendar year. The purpose of this form is to help ensure that food establishments are following all laws and regulations related to employee count. Completing this form accurately is important, as it can help protect both employees and customers.

Question	Answer
Form Name	Form Cdph 110A
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	CMRcdph0110a confidential morbidity report san bernardino county form

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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

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

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			Treatment Began	Will treat
Drug(s), Dosage, Route			(mm/dd/yyyy)	Will treat
				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)

Yes

Gonococcal PID

Cervical

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)
	Blood transfusion, dental or	ALT (SGPT)
	medical procedure			Upper
	medical procedure

	IV drug use	Result: _____		Limit: _____
	Other needle exposure
	Sexual contact	AST (SGOT)
	Sexual contact			Upper
	Household contact			Upper
	Household contact	Result: _____		Limit: _____
		Result: _____		Limit: _____
	Perinatal
	Child care	Bilirubin result: ____________
		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			HCV RNA
	anti-HBc total			(e.g., PCR)
	anti-HBc IgM			(e.g., PCR)
	anti-HBc IgM
	anti-HBs		Hep D	anti-HDV
	HBeAg		Hep E	anti-HEV
	anti-HBe		Hep E	anti-HEV
	anti-HBe
	HBV DNA: ___________

Remarks:

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

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State of California—Health and Human Services Agency

California Department of Public Health

CDPH 110a (1/11)

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Form Cdph 110A PDF Details

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