Form CDPH8421 "Poliovirus Infection or Poliomyelitis Case Report" - California

What Is Form CDPH8421?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2010;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CDPH8421 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH8421 "Poliovirus Infection or Poliomyelitis Case Report" - California

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California Department of Public Health
State of California—Health and Human Services Agency
Surveillance and Statistics Section
MS 7306
P.O. Box 997377
Sacramento, CA 95899-7377
POLIOVIRUS INFECTION OR POLIOMYELITIS CASE REPORT
FOR STATE/DCDC USE ONLY:
REPORT YEAR:
DATE CASE STATUS IS DETERMINED:
Patient name–last
first
middle initial
Date of birth
Age
Sex
Address–number, street
City
State
County
ZIP code
Telephone number
County (where infected if different from address)
(
)
(
)
Home
Work
RACE (check one)
ETHNICITY (check one)
African-American/Black
White
Native American
Asian/Pacific Islander
Other _____________________
Hispanic/Latino
Non-Hispanic/Non-Latino
If Asian/Pacific Islander, please check one:
Asian Indian
Cambodian
Chinese
Filipino
Guamanian
Hawaiian
Japanese
Korean
Laotian
Samoan
Vietnamese
Other
________________
CLINICAL DATA
Illness onset date
Weakness/paralysis
Hospitalized
Attending physician or consultant physician
Telephone number
onset date
(mm/dd/yy)
(mm/dd/yy)
(
)
Yes
No
Admit date
Discharge date
Medical record number Hospital name
Telephone number
(mm/dd/yy)
(mm/dd/yy)
(
)
Describe symptoms, signs (fever, gastrointestinal symptoms, meningeal irritation, myalgia; type—flaccid vs. plastic/rigid—distribution and progress of paralysis):
None
Died
Residual weakness, describe below:
Paralysis/muscle weakness status 60 days after weakness/paralysis onset:
LABORATORY DATA
(This section is continued on the reverse of this form.)
VIRUS ISOLATION (Throat washing, stool, rectal swab, CSF)
Type of Specimen
Date Collected
Result of the Test
Describe strain characterization of any poliovirus isolated (vaccine vs. wild type). Do not wait for this result before sending form to Department of Health Services.
SEROLOGIC DATA (Collection dates and results of acute and convalescent sera for polio CF and/or neutralization antibody test for all three (3) poliovirus types or for
other possible agents)
Polio CF Titers
Polio Neut. Titers
Other Agents
Date Collected
Type 1
Type 2
Type 3
Type 1
Type 2
Type 3
CSF (Collection date(s), protein, white cell count and differential, glucose)
Date Collected
WBC Count and Differential
Protein
Glucose
CDPH 8421 (12/2010)
Page 1 of 2
California Department of Public Health
State of California—Health and Human Services Agency
Surveillance and Statistics Section
MS 7306
P.O. Box 997377
Sacramento, CA 95899-7377
POLIOVIRUS INFECTION OR POLIOMYELITIS CASE REPORT
FOR STATE/DCDC USE ONLY:
REPORT YEAR:
DATE CASE STATUS IS DETERMINED:
Patient name–last
first
middle initial
Date of birth
Age
Sex
Address–number, street
City
State
County
ZIP code
Telephone number
County (where infected if different from address)
(
)
(
)
Home
Work
RACE (check one)
ETHNICITY (check one)
African-American/Black
White
Native American
Asian/Pacific Islander
Other _____________________
Hispanic/Latino
Non-Hispanic/Non-Latino
If Asian/Pacific Islander, please check one:
Asian Indian
Cambodian
Chinese
Filipino
Guamanian
Hawaiian
Japanese
Korean
Laotian
Samoan
Vietnamese
Other
________________
CLINICAL DATA
Illness onset date
Weakness/paralysis
Hospitalized
Attending physician or consultant physician
Telephone number
onset date
(mm/dd/yy)
(mm/dd/yy)
(
)
Yes
No
Admit date
Discharge date
Medical record number Hospital name
Telephone number
(mm/dd/yy)
(mm/dd/yy)
(
)
Describe symptoms, signs (fever, gastrointestinal symptoms, meningeal irritation, myalgia; type—flaccid vs. plastic/rigid—distribution and progress of paralysis):
None
Died
Residual weakness, describe below:
Paralysis/muscle weakness status 60 days after weakness/paralysis onset:
LABORATORY DATA
(This section is continued on the reverse of this form.)
VIRUS ISOLATION (Throat washing, stool, rectal swab, CSF)
Type of Specimen
Date Collected
Result of the Test
Describe strain characterization of any poliovirus isolated (vaccine vs. wild type). Do not wait for this result before sending form to Department of Health Services.
SEROLOGIC DATA (Collection dates and results of acute and convalescent sera for polio CF and/or neutralization antibody test for all three (3) poliovirus types or for
other possible agents)
Polio CF Titers
Polio Neut. Titers
Other Agents
Date Collected
Type 1
Type 2
Type 3
Type 1
Type 2
Type 3
CSF (Collection date(s), protein, white cell count and differential, glucose)
Date Collected
WBC Count and Differential
Protein
Glucose
CDPH 8421 (12/2010)
Page 1 of 2
CDPH 8421—Page 2 of 2
LABORATORY DATA (Continued)
Electromyogram, nerve conduction study, other test, describe if any (specify date and findings):
Stool tested for C. botulinum organism/toxin, describe:
Serlim tested for C. botulinum toxin, describe:
Immunocompetence work-up (e.g., WBC, quantitative immunoglobulins, T and B cell quantitation, lymphocyte transmation, HL-A), describe:
Immunodeficiency clinically evident:
Yes
No
Unknown
Botulism culture/toxin assay:
Date: _______________________
Findings: ______________________________________________________________________________
EPIDEMIOLOGIC DATA
History of receipt of oral polio vaccine (OPV) ≤ 30 days before onset:
Yes
No
Unknown
Full polio immunization history, specify date and vaccine type: ______________________________________________________________________________________________
History of contact with person who received OPV ≤ 75 days before onset of case’s symptoms:
Yes
No
Unknown
If yes, describe relationship/contact of vaccinee to case, dates of immunization, and contact: ______________________________________________________________________
Dose number of OPV received by contact:
First
Second
Third
Fourth
>Fifth
Foreign travel or foreign visitors in the 30-day period before onset:
Yes
No
Unknown
If yes, describe in details (dates of contact, illness signs and symptoms, etc.): __________________________________________________________________________________
Other cases of polio-like illness in the community or in contact with the case ≤ 30 days before onset:
Yes
No
Unknown
If yes, describe in details (dates of contact, illness signs and symptoms, etc.): __________________________________________________________________________________
REMARKS
Investigator name (print)
Date
Telephone number
(
)
Agency name
CASE DEFINITIONS
Poliovirus infection, non-paralytic
CASE DEFINITION 2010 - CSTE Position Statement Number: 09-ID-53
Case classification:
Confirmed: Any person without symptoms of paralytic poliomyelitis in whom a poliovirus isolate was identified in an appropriate clinical specimen, with confirmatory typing and sequencing performed by the
CDC Poliovirus Laboratory, as needed.
*Note that this case definition applies only to poliovirus infections found in asymptomatic persons or those with mild, nonparalytic disease (e.g., those with a nonspecific febrile illness,
diarrhea, or aseptic meningitis). Isolation of polioviruses from persons with acute paralytic poliomyelitis should continue to be reported as "paralytic poliomyelitis."
Poliomyelitis, paralytic
CASE DEFINITION 2010 - CSTE Position Statement Number: 09-ID-53
Case classification:
Probable: Acute onset of a flaccid paralysis of one or more limbs with decreased or absent tendon reflexes in the affected limbs, without other apparent cause, and without sensory or cognitive loss.
Confirmed: Acute onset of a flaccid paralysis of one or more limbs with decreased or absent tendon reflexes in the affected limbs, without other apparent cause, and without sensory or cognitive loss;
AND in which the patient has a neurologic deficit 60 days after onset of initial symptoms; OR has died; OR has unknown follow-up status.
CDPH 8421 (12/2010)
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