Form CDPH8640 "Salmonellosis Case Report" - California

What Is Form CDPH8640?

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 August 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 CDPH8640 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 CDPH8640 "Salmonellosis 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
SALMONELLOSIS
CASE REPORT
Please note: Prompt, standardized interview of all cases of salmonellosis is strongly encouraged to improve the accuracy of recall of
possible vehicles of infection. Jurisdictions that choose to use this form should maintain the form at the local jurisdiction to be provided
to the State’s Infectious Diseases Branch staff if the patient is identified as part of a cluster or outbreak investigation. For jurisdictions
participating in CalREDIE, entry into the CalREDIE form or scanning and uploading into the CalREDIE filing cabinet will facilitate cluster
investigations and surveillance analysis. Please do not fax or send hard copy of the forms to the State unless requested.
PATIENT INFORMATION
Last Name
First Name
Middle Name
Suffix
Primary Language
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 8)
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 8)
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 8)
Other Describe/Specify
more than one racial designation.
CLINICAL INFORMATION
Physician Name - Last Name
First Name
Telephone Number
GROUP SETTING
Attend child care or preschool?
Location / Other Details of Child Care, Preschool, or Skilled Nursing Facility
Yes No Unk
Live in skilled nursing facility?
Yes No Unk
CDPH 8640 (revised 08/11)
Page 1 of 8
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
SALMONELLOSIS
CASE REPORT
Please note: Prompt, standardized interview of all cases of salmonellosis is strongly encouraged to improve the accuracy of recall of
possible vehicles of infection. Jurisdictions that choose to use this form should maintain the form at the local jurisdiction to be provided
to the State’s Infectious Diseases Branch staff if the patient is identified as part of a cluster or outbreak investigation. For jurisdictions
participating in CalREDIE, entry into the CalREDIE form or scanning and uploading into the CalREDIE filing cabinet will facilitate cluster
investigations and surveillance analysis. Please do not fax or send hard copy of the forms to the State unless requested.
PATIENT INFORMATION
Last Name
First Name
Middle Name
Suffix
Primary Language
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 8)
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 8)
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 8)
Other Describe/Specify
more than one racial designation.
CLINICAL INFORMATION
Physician Name - Last Name
First Name
Telephone Number
GROUP SETTING
Attend child care or preschool?
Location / Other Details of Child Care, Preschool, or Skilled Nursing Facility
Yes No Unk
Live in skilled nursing facility?
Yes No Unk
CDPH 8640 (revised 08/11)
Page 1 of 8
California Department of Public Health
SALMONELLOSIS CASE REPORT
First three letters of
patient’s last name:
SIGNS AND SYMPTOMS
Symptomatic?
Onset Date (mm/dd/yyyy)
Onset Time (hh:mm)
Specify AM/PM
Duration of Acute Symptoms (days)
Yes No Unk
AM PM
Signs and Symptoms
Yes
No
Unk
If Yes, Specify as Noted
Max. number of stools in 24-hr period
Onset date of diarrhea (mm/dd/yyyy)
Diarrhea
Bloody diarrhea
Highest temperature (specify °F/°C)
Fever
Vomiting
Abdominal cramps
Chills
Other signs / symptoms (specify)
PAST MEDICAL HISTORY
Did the patient take antibiotics in the month prior to onset?
If Yes, specify antibiotic(s)
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
TREATMENT / MANAGEMENT
Received treatment?
If Yes, specify the treatments below.
Yes No Unk
TREATMENT / MANAGEMENT DETAILS
Treatment Type 1
Treatment Name
Date Started (mm/dd/yyyy)
Date Ended (mm/dd/yyyy)
Antibiotic Other
Treatment Type 2
Treatment Name
Date Started (mm/dd/yyyy)
Date Ended (mm/dd/yyyy)
Antibiotic Other
CDPH 8640 (revised 08/11)
Page 2 of 8
California Department of Public Health
SALMONELLOSIS CASE REPORT
First three letters of
patient’s last name:
OUTCOME
Outcome?
Date of Death (mm/dd/yyyy)
If Survived,
Survived as of ________________________________(mm/dd/yyyy)
Survived Died Unk
LABORATORY INFORMATION
LABORATORY RESULTS SUMMARY
Specimen Type 1
Collection Date (mm/dd/yyyy)
Laboratory Name
Telephone Number
Stool
Blood
Was result confirmed by local public health lab?
Result (including subtype)
Local Lab ID Number
Urine
Yes
No
Unk
Other (specify):
Was isolate sent to state lab for serotyping confirmation?
Result (including serotype)
State Lab ID Number
__________________
Yes
No
Unk
Was PFGE requested?
Xbal Pattern #
Binl Pattern #
CDC Cluster ID #
__________________
Yes
No
Unk
Specimen Type 2
Collection Date (mm/dd/yyyy)
Laboratory Name
Telephone Number
Stool
Blood
Was result confirmed by local public health lab?
Result (including subtype)
Local Lab ID Number
Urine
Yes
No
Unk
Other (specify):
Was isolate sent to state lab for serotyping confirmation?
Result (including serotype)
State Lab ID Number
__________________
Yes
No
Unk
Was PFGE requested?
Xbal Pattern #
Binl Pattern #
CDC Cluster ID #
__________________
Yes
No
Unk
EPIDEMIOLOGIC INFORMATION
INCUBATION PERIOD: 7 DAYS PRIOR TO ILLNESS ONSET
FOOD HISTORY
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
Eaten undercooked or raw?
Where purchased
Eggs
Yes
No
Unk
Food made with raw eggs
Food items
Where purchased
(e.g., eggnog, Caesar salad
dressing, cookie dough,
homemade mayonnaise)
Type(s)
Brand(s)
Where purchased
Raw (unpasteurized) milk
Type(s)
Brand(s)
Where purchased
Raw milk products
Unpasteurized?
Brand(s)
Where purchased
Mexican-style fresh cheese (queso
Yes
No
Unk
fresco) or cheese from a street
vendor
Type(s)
Eaten undercooked or raw?
Where purchased
Ground beef
Yes
No
Unk
Type(s)
Eaten undercooked or raw?
Where purchased
Poultry
Yes
No
Unk
Type(s)
Eaten undercooked or raw?
Where purchased
Other meat (e.g., pork, lamb,
goat, etc.)
Yes
No
Unk
Type(s)
Where purchased
Raw nuts
Type(s)
Where purchased
Tomatoes
(continued on page 4)
CDPH 8640 (revised 08/11)
Page 3 of 8
California Department of Public Health
SALMONELLOSIS CASE REPORT
First three letters of
patient’s last name:
FOOD HISTORY (continued)
Food Item
Yes
No
Unk
If Yes, Specify as Noted
Type(s)
Where purchased
Lettuce
Where purchased
Cilantro
Where purchased
Green onions
Where purchased
Bean sprouts
Where purchased
Alfalfa sprouts
Type(s)
Where purchased
Other raw vegetables
Where purchased
Fresh salsa
Where purchased
Cantaloupe
Type(s)
Where purchased
Other raw fresh fruit
Raw (unpasteurized) juices, ciders,
Type(s)
Brand(s)
Where purchased
smoothies
Food item(s)
Where purchased
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 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
(continued on page 5)
CDPH 8640 (revised 08/11)
Page 4 of 8
California Department of Public Health
SALMONELLOSIS CASE REPORT
First three letters of
patient’s last name:
FOOD HISTORY - OUTSIDE HOME - DETAILS
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
ANIMAL EXPOSURES
DID THE PATIENT HAVE ANY OF THE FOLLOWING ANIMAL EXPOSURES DURING THE INCUBATION PERIOD?
Animal Exposures
Yes
No
Unk
Type(s) of Animals
Animal ill?
Setting/Location
Date (mm/dd/yyyy)
Birds
Yes No Unk
Reptiles
Yes No Unk
Other pet
Yes No Unk
Livestock (e.g., cows, pigs, sheep, goats)
Yes No Unk
Farms
Yes No Unk
Animal exhibits (e.g., petting zoos, fairs)
Yes No Unk
Other animal exposures of interest
Yes No Unk
WATER EXPOSURES
DID THE PATIENT HAVE ANY OF THE FOLLOWING WATER EXPOSURES DURING THE INCUBATION PERIOD?
Water Source
Yes
No
Unk
Activity
Location
Date (mm/dd/yyyy)
Natural: rivers, lakes, oceans, etc.
Artificial: swimming pools, water parks,
fountains, etc.
Other water exposures of interest
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)
CDPH 8640 (revised 08/11)
Page 5 of 8