Form CDPH8526 "Human Rabies Case Report" - California

What Is Form CDPH8526?

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 printable version of Form CDPH8526 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 CDPH8526 "Human Rabies Case Report" - California

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State of California—Health and Human Services Agency
California Department of Public Health
Center for Infectious Diseases
Local ID Number ___________________________
Division of Communicable Disease Control
Infectious Diseases Branch
(Please use the same ID Number on the preliminary
Surveillance and Statistics Section
and final reports to allow linkage to the same case.)
MS 7306, P.O. Box 997377
Sacramento, CA 95899-7377
Report Status (check one)
Preliminary
Final
HUMAN RABIES
CASE REPORT
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
CDPH 8526 (revised 04/11)
Page 1 of 7
State of California—Health and Human Services Agency
California Department of Public Health
Center for Infectious Diseases
Local ID Number ___________________________
Division of Communicable Disease Control
Infectious Diseases Branch
(Please use the same ID Number on the preliminary
Surveillance and Statistics Section
and final reports to allow linkage to the same case.)
MS 7306, P.O. Box 997377
Sacramento, CA 95899-7377
Report Status (check one)
Preliminary
Final
HUMAN RABIES
CASE REPORT
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
CDPH 8526 (revised 04/11)
Page 1 of 7
California Department of Public Health
HUMAN RABIES 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)
Yes No Unk
Signs and Symptoms
Yes
No
Unk
Signs and Symptoms
Yes
No
Unk
Fever
Ataxia
If Yes, highest temperature:
_________ specify °F/°C
Priapism
Encephalitis
Seizures
Myelitis
Hydrophobia
Ascending flaccid paralysis
Localized weakness
Aerophobia
Localized pain or paraesthesia
Malaise
Confusion or delirium
Headache
Agitation or combativeness
Nausea or vomiting
Autonomic instability
Anxiety
Hyperactivity
Muscle spasm
Hallucinations
Dysphagia
Insomnia
Anorexia
Hypersalivation
Other signs / symptoms (specify)
PAST MEDICAL HISTORY - RABIES VACCINATION
If the patient has a history of rabies vaccination(s), please specify below.
Vaccine Name 1
Date of Vaccination (mm/dd/yyyy)
Vaccine Name 2
Date of Vaccination (mm/dd/yyyy)
Vaccine Name 3
Date of Vaccination (mm/dd/yyyy)
PAST MEDICAL HISTORY - OTHER
Other condition?
If Yes, specify
Yes No Unk
CDPH 8526 (revised 04/11)
Page 2 of 7
California Department of Public Health
HUMAN RABIES CASE REPORT
First three letters of
patient’s last name:
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
COMA
Was the patient in a coma?
If Yes, coma onset date (mm/dd/yyyy)
Additional Information
Yes No Unk
TREATMENT / MANAGEMENT
Local treatment of wound?
Additional Information
If Yes, date of treatment (mm/dd/yyyy)
Yes No Unk
Postexposure prophylaxis?
If Yes, specify type of products
If Yes, specify the treatments below.
Yes No Unk
TREATMENT / MANAGEMENT - DETAILS
Rabies immune globulin given?
Number of Doses
Date Administered (mm/dd/yyyy)
Yes No Unk
Manufacturer
Lot Number
Rabies vaccine given?
Number of Doses
First Dose (mm/dd/yyyy)
Last Dose (mm/dd/yyyy)
Yes No Unk
Manufacturer
Lot Number
OUTCOME
Outcome?
If Survived, Survived as of (mm/dd/yyyy)
Date of Death (mm/dd/yyyy)
Survived Died Unk
CDPH 8526 (revised 04/11)
Page 3 of 7
California Department of Public Health
HUMAN RABIES CASE REPORT
First three letters of
patient’s last name:
LABORATORY INFORMATION
LABORATORY RESULTS SUMMARY
Specimen Type 1
Collection Date (mm/dd/yyyy)
Type of Test
Serum
CSF
IFA
RFFIT
DFA
PCR
Other:__________________
Nuchal biopsy
Brain
Results
If Serum, specify titer
Interpretation
Corneal Impression
Saliva
Positive
Negative
Equivocal
Other:_________________
Laboratory Name
Telephone Number
Specimen Type 2
Collection Date (mm/dd/yyyy)
Type of Test
Serum
CSF
IFA
RFFIT
DFA
PCR
Other:__________________
Nuchal biopsy
Brain
Results
If Serum, specify titer
Interpretation
Corneal Impression
Saliva
Positive
Negative
Equivocal
Other:_________________
Laboratory Name
Telephone Number
EPIDEMIOLOGIC INFORMATION
INCUBATION PERIOD: 12 MONTHS PRIOR TO ILLNESS ONSET
ANIMAL EXPOSURES
Did the patient come into contact with animal(s) during the incubation period?
If Yes, specify animal exposures below.
Yes
No
Unk
ANIMAL EXPOSURES - DETAILS
Animal 1
Type of Exposure
If bitten, specify Anatomic Site and County where bite occurred
No known exposure
Bat
Fox
Bite
Anatomic Site of Bite
County
Nonbite (scratch)
Skunk
Dog
Unk
Nonbite (contact)
Other: _______________
Raccoon
Cat
Other:___________________
Exposure Start Date (mm/dd/yyyy)
Exposure Start Date (mm/dd/yyyy)
Exposure Circumstances
Animal 2
Type of Exposure
If bitten, specify Anatomic Site and County where bite occurred
No known exposure
Bat
Fox
Bite
Anatomic Site of Bite
County
Nonbite (scratch)
Skunk
Dog
Unk
Nonbite (contact)
Other: _______________
Raccoon
Cat
Other:___________________
Exposure Start Date (mm/dd/yyyy)
Exposure Start Date (mm/dd/yyyy)
Exposure Circumstances
OCCUPATIONAL / RECREATIONAL EXPOSURES
Rabies laboratory?
Laboratory Name
Exposure Activity
Yes
No
Unk
Other occupational/recreational exposures?
If Yes, specify
Yes
No
Unk
CDPH 8526 (revised 04/11)
Page 4 of 7
California Department of Public Health
HUMAN RABIES CASE REPORT
First three letters of
patient’s last name:
TRAVEL HISTORY
Did patient travel outside of 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
Date of Contact (mm/dd/yyyy)
Street Address
Exposure Event
Illness Onset Date (mm/dd/yyyy)
City
State
Zip Code
Date First Reported to Public Health (mm/dd/yyyy)
Age
Gender
Telephone Number
Type of Contact / Relationship
Date of Contact (mm/dd/yyyy)
Name 2
Street Address
Exposure Event
Illness Onset Date (mm/dd/yyyy)
City
State
Zip Code
Date First Reported to Public Health (mm/dd/yyyy)
NOTES / REMARKS
CDPH 8526 (revised 04/11)
Page 5 of 7