Form CDPH8296 "Listeriosis Case Report" - California

What Is Form CDPH8296?

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 April 1, 2011;
  • 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 CDPH8296 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 CDPH8296 "Listeriosis Case Report" - California

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State of California—Health and Human Services Agency
Local ID Number ___________________________
California Department of Public Health
Center for Infectious Diseases
(Please use the same ID Number on the preliminary
Division of Communicable Disease Control
and final reports to allow linkage to the same case.)
Infectious Diseases Branch
Surveillance and Statistics Section
Report Status (check one)
MS 7306, P.O. Box 997377
Preliminary
Final
Sacramento, CA 95899-7377
LISTERIOSIS
CASE REPORT
Red boxes indicate required fields
PATIENT INFORMATION
Primary Language
Last Name
First Name
Middle Name
Suffix
English
Spanish
Social Security Number (9 digits)
DOB (mm/dd/yyyy)
Age
Years
Other:_____________________
Months
Days
Ethnicity (check one)
Address Number & Street - Residence
Apartment/Unit Number
Hispanic/Latino
Non-Hispanic/Non-Latino
Unk
City/Town
State
Zip Code
Race*
(check all that apply, race descriptions on page 7)
Census Tract
County of Residence
Country of Residence
African-American/Black
American Indian or Alaska Native
Country of Birth
If not U.S. Born - Date of Arrival in U.S. (mm/dd/yyyy)
Asian (check all that apply)
Asian Indian
Japanese
Home Telephone
Cellular Phone/Pager
Work/School Telephone
Cambodian
Korean
Chinese
Laotian
Filipino
Thai
E-mail Address
Other Electronic Contact Information
Hmong
Vietnamese
Other:_____________________
Work/School Location
Work/School Contact
Pacific Islander (check all that apply)
Native Hawaiian
Samoan
Gender
Guamanian
Other: _______________________________
Male
Female
Other:_____________________
Pregnant?
If Yes, Est. Delivery Date (mm/dd/yyyy)
White
Yes
No
Unk
Other:____________________
Medical Record Number
Patient’s Parent/Guardian Name
Unk
*Comment: self-identity or self-reporting
Occupation Setting (see list on page 7)
Other Describe/Specify
The response to this item should be based on the
patient’s self-identity or self-reporting. Therefore,
patients should be offered the option of selecting
Occupation (see list on page 7)
Other Describe/Specify
more than one racial designation.
CLINICAL INFORMATION
Physician Name - Last Name
First Name
Telephone Number
Clear Page
Page 1 of 7
CDPH 8296 (revised 04/11)
State of California—Health and Human Services Agency
Local ID Number ___________________________
California Department of Public Health
Center for Infectious Diseases
(Please use the same ID Number on the preliminary
Division of Communicable Disease Control
and final reports to allow linkage to the same case.)
Infectious Diseases Branch
Surveillance and Statistics Section
Report Status (check one)
MS 7306, P.O. Box 997377
Preliminary
Final
Sacramento, CA 95899-7377
LISTERIOSIS
CASE REPORT
Red boxes indicate required fields
PATIENT INFORMATION
Primary Language
Last Name
First Name
Middle Name
Suffix
English
Spanish
Social Security Number (9 digits)
DOB (mm/dd/yyyy)
Age
Years
Other:_____________________
Months
Days
Ethnicity (check one)
Address Number & Street - Residence
Apartment/Unit Number
Hispanic/Latino
Non-Hispanic/Non-Latino
Unk
City/Town
State
Zip Code
Race*
(check all that apply, race descriptions on page 7)
Census Tract
County of Residence
Country of Residence
African-American/Black
American Indian or Alaska Native
Country of Birth
If not U.S. Born - Date of Arrival in U.S. (mm/dd/yyyy)
Asian (check all that apply)
Asian Indian
Japanese
Home Telephone
Cellular Phone/Pager
Work/School Telephone
Cambodian
Korean
Chinese
Laotian
Filipino
Thai
E-mail Address
Other Electronic Contact Information
Hmong
Vietnamese
Other:_____________________
Work/School Location
Work/School Contact
Pacific Islander (check all that apply)
Native Hawaiian
Samoan
Gender
Guamanian
Other: _______________________________
Male
Female
Other:_____________________
Pregnant?
If Yes, Est. Delivery Date (mm/dd/yyyy)
White
Yes
No
Unk
Other:____________________
Medical Record Number
Patient’s Parent/Guardian Name
Unk
*Comment: self-identity or self-reporting
Occupation Setting (see list on page 7)
Other Describe/Specify
The response to this item should be based on the
patient’s self-identity or self-reporting. Therefore,
patients should be offered the option of selecting
Occupation (see list on page 7)
Other Describe/Specify
more than one racial designation.
CLINICAL INFORMATION
Physician Name - Last Name
First Name
Telephone Number
Clear Page
Page 1 of 7
CDPH 8296 (revised 04/11)
California Department of Public Health
LISTERIOSIS CASE REPORT
First three letters of
patient’s last name:
SIGNS AND SYMPTOMS
Symptomatic?
Onset Date (mm/dd/yyyy)
Date First Sought Medical Care (mm/dd/yyyy)
Duration of Acute Symptoms (days)
Yes No Unk
Note: For Signs and Symptoms listed below, please review medical records. This is necessary for proper case classification. If the patient was hospitalized,
please provide copy of discharge summary.
Signs and Symptoms
Yes
No
Unk
If Yes, Specify as Noted
Meningitis
Bacteremia / sepsis
If Yes, highest temperature (specify °F/°C)
Febrile gastroenteritis
Amnionitis
Miscarriage / stillbirth
Pneumonia (neonate)
Granulomatosis infantisepticum
(neonate)
Other signs / symptoms (specify)
PAST MEDICAL HISTORY
Was the patient pregnant at onset?
If Yes, weeks gestation
Yes No Unk
Does the patient take any medications regularly?
If Yes, specify medication(s)
Yes No Unk
Does the patient have any medical conditions? (i.e., renal disease, diabetes,
If Yes, specify medical condition(s)
immune compromising conditions)
Yes No Unk
HOSPITALIZATION
Did patient visit emergency room for illness?
Was patient hospitalized?
If Yes, how many total hospital nights?
Yes No Unk
Yes No Unk
If there were any ER or hospital stays related to this illness, specify details below.
HOSPITALIZATION - DETAILS
Hospital Name 1
Street Address
Admit Date (mm/dd/yyyy)
City
Discharge / Transfer Date (mm/dd/yyyy)
State
Zip Code
Telephone Number
Medical Record Number
Discharge Diagnosis
Hospital Name 2
Street Address
Admit Date (mm/dd/yyyy)
City
Discharge / Transfer Date (mm/dd/yyyy)
State
Zip Code
Telephone Number
Medical Record Number
Discharge Diagnosis
Clear Page
Page 2 of 7
CDPH 8296 (revised 04/11)
California Department of Public Health
LISTERIOSIS CASE REPORT
First three letters of
patient’s last name:
OUTCOME
Outcome?
If Survived,
Date of Death (mm/dd/yyyy)
Survived as of ________________________________(mm/dd/yyyy)
Survived Died Unk
If patient was pregnant, outcome of fetus?
Born alive but died within seven days
Alive, with complications
Alive and well
Stillborn
LABORATORY INFORMATION
LABORATORY RESULTS SUMMARY
Specimen Type
* If pregnancy-associated, specify if Blood or CSF specimen is from mother
or neonate
Other:________________
Blood*
CSF*
Placenta
Stool
Mother
Neonate
Collection Date (mm/dd/yyyy)
Results
Laboratory Name
Telephone Number
Was result confirmed by local public health lab?
Result (including subtype)
Local Lab ID Number
Yes No Unk
Was isolate sent to state lab for serotyping confirmation?
Result (including serotype)
State Lab ID Number
Yes No Unk
Was PFGE requested?
Pattern 1 #
Pattern 2 #
CDC Cluster ID # (if known)
Yes No Unk
EPIDEMIOLOGIC INFORMATION
INCUBATION PERIOD: 28 DAYS PRIOR TO ILLNESS ONSET
EXPOSURES / RISK FACTORS
If NEONATE / INFANT: Was listeriosis confirmed in mother?
If Yes, explain
Yes
No
Unk
If NEONATE: Did birth mother have febrile illness during this pregnancy?
If Yes, explain
Yes
No Unk
DID THE PATIENT EAT OR DRINK ANY OF THE FOLLOWING ITEMS DURING THE INCUBATION PERIOD?
Food Item
Yes
No
Unk
If Yes, Specify as Noted
Cold cuts sliced at a deli, (e.g.,
Type(s)
Where purchased
turkey breast, ham, pastrami)
Type(s)
Brand(s)
Where purchased
Pre-packaged cold cuts
Type(s)
Brand(s)
Hot dogs
Eaten right out of the package?
Where purchased
Yes
No
Unk
Refrigerated pâté or meat spreads,
Type(s)
Brand(s)
Where purchased
not canned
Refrigerated, smoked, or cured
Type(s)
Brand(s)
Where purchased
seafood (e.g., salmon, whitefish,
trout), not canned
Type(s)
Brand(s)
Where purchased
Raw (unpasteurized) milk
Type(s)
Brand(s)
Where purchased
Raw milk products
Unpasteurized?
Type(s)
Mexican-style fresh cheese
Yes
No
Unk
(queso fresco) or cheese from
Brand(s)
Location(s) Where Cheese Obtained
a street vendor
(continued on page 4)
Clear Page
Page 3 of 7
CDPH 8296 (revised 04/11)
California Department of Public Health
LISTERIOSIS CASE REPORT
First three letters of
patient’s last name:
Food Item
Yes
No
Unk
If Yes, Specify as Noted
Type(s)
Brand(s)
Where purchased
Soft cheese (e.g., Brie, feta,
Camembert, goat, blue)
Ready-to-eat deli style salads
Type(s)
Brand(s)
Where purchased
(e.g., potato salad, pasta salad,
tuna salad)
Type(s)
Brand(s)
Where purchased
Pre-prepared dips (e.g., hummus)
Specify food item(s)
Other food exposures of interest
FOOD HISTORY - GROCERIES
WHERE DID PATIENT SHOP FOR GROCERIES? (INCLUDE FARMER’S MARKETS, DELIS, SWAP MEETS, ETC.)
Store / Location 1
Address / Cross-streets
City
State
Store / Location 2
Address / Cross-streets
City
State
Store / Location 3
Address / Cross-streets
City
State
FOOD HISTORY - OUTSIDE HOME
Did the patient consume food or drink prepared outside of the home during
If Yes, specify name of place (e.g., restaurant, concession stand, friend’s
the incubation period?
house, etc.), location, date, and items consumed below.
Yes
No
Unk
FOOD HISTORY - OUTSIDE HOME - DETAILS
Name of Place 1
Location (city, state)
Date (mm/dd/yyyy)
Items Consumed
Name of Place 2
Location (city, state)
Date (mm/dd/yyyy)
Items Consumed
Name of Place 3
Location (city, state)
Date (mm/dd/yyyy)
Items Consumed
Name of Place 4
Location (city, state)
Date (mm/dd/yyyy)
Items Consumed
Clear Page
Page 4 of 7
CDPH 8296 (revised 04/11)
California Department of Public Health
LISTERIOSIS CASE REPORT
First three letters of
patient’s last name:
TRAVEL HISTORY
Did patient travel outside county of residence during the incubation period?
If Yes, specify all locations and dates below.
Yes
No
Unk
TRAVEL HISTORY - DETAILS
Location (city, county, state, country)
Date Travel Started (mm/dd/yyyy)
Date Travel Ended (mm/dd/yyyy)
ILL CONTACTS
Any contacts with similar illness (including household contacts)?
If Yes, specify details below.
Yes No Unk
ILL CONTACTS - DETAILS
Name 1
Age
Gender
Telephone Number
Type of Contact / Relationship
Street Address
Date of Contact (mm/dd/yyyy)
Illness Onset Date (mm/dd/yyyy)
City
State
Zip Code
Exposure Event
Name 2
Age
Gender
Telephone Number
Type of Contact / Relationship
Street Address
Date of Contact (mm/dd/yyyy)
Illness Onset Date (mm/dd/yyyy)
City
State
Zip Code
Exposure Event
NOTES / REMARKS
Clear Page
Page 5 of 7
CDPH 8296 (revised 04/11)