Form CDPH8606 "Trichinosis Case Report" - California

What Is Form CDPH8606?

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 November 1, 2014;
  • 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 CDPH8606 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 CDPH8606 "Trichinosis 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
TRICHINOSIS
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 6)
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
 Cambodian
 Korean
Home Telephone
Cellular Phone / Pager
Work / School Telephone
 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
 Male
 Female
 Other: _______________________________
 Other:_____________________
 White
Pregnant?
If Yes, Est. Delivery Date (mm/dd/yyyy)
 Yes
 No
 Unk
 Other:____________________
 Unk
Medical Record Number
Patient’s Parent / Guardian Name
*Comment: self-identity or self-reporting
Occupation Setting (see list on page 6)
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 6)
Other (Describe / Specify)
more than one racial designation.
CLINICAL INFORMATION
Physician Name - Last Name
First Name
Telephone Number
CDPH 8606 (revised 11/14)
Page 1 of 6
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
TRICHINOSIS
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 6)
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
 Cambodian
 Korean
Home Telephone
Cellular Phone / Pager
Work / School Telephone
 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
 Male
 Female
 Other: _______________________________
 Other:_____________________
 White
Pregnant?
If Yes, Est. Delivery Date (mm/dd/yyyy)
 Yes
 No
 Unk
 Other:____________________
 Unk
Medical Record Number
Patient’s Parent / Guardian Name
*Comment: self-identity or self-reporting
Occupation Setting (see list on page 6)
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 6)
Other (Describe / Specify)
more than one racial designation.
CLINICAL INFORMATION
Physician Name - Last Name
First Name
Telephone Number
CDPH 8606 (revised 11/14)
Page 1 of 6
California Department of Public Health
TRICHINOSIS 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
If Yes, Specify as Noted
Highest temperature (specify °F/°C)
Fever
Myalgia
Absolute number (#)
Percentage (%)
Eosinophilia (EM)
Periorbital edema
Other signs / symptoms (specify)
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
OUTCOME
Outcome?
If Survived,
Date of Death (mm/dd/yyyy)
 Survived
 Died
 Unk
Survived as of ________________________________(mm/dd/yyyy)
LABORATORY INFORMATION
LABORATORY RESULTS SUMMARY
Specimen Type 1
Collection Date (mm/dd/yyyy)
Type of Test
 Serum (acute)
 Trichinella sp. serology
 Muscle biopsy
 Other:_____________
 Serum (convalescent)
Result
Interpretation
 Muscle
 Positive
 Negative
 Equivocal
 Other:_________________
Laboratory Name
Telephone Number
If Serum (acute) is submitted, then Serum
(convalescent) must also be submitted.
Specimen Type 2
Type of Test
Collection Date (mm/dd/yyyy)
 Serum (acute)
 Trichinella sp. serology
 Muscle biopsy
 Other:_____________
 Serum (convalescent)
Result
Interpretation
 Muscle
 Positive
 Negative
 Equivocal
 Other:_________________
Laboratory Name
Telephone Number
If Serum (acute) is submitted, then Serum
(convalescent) must also be submitted.
CDPH 8606 (revised 11/14)
Page 2 of 6
California Department of Public Health
TRICHINOSIS CASE REPORT
First three letters of
patient’s last name:
EPIDEMIOLOGIC INFORMATION
FOOD HISTORY (six weeks preceding onset of illness)
Did patient eat pork?
If Yes, specify type of pork below.
 Yes
 No
 Unk
Type of Pork
Yes
No
Unk
If Yes, Specify as Noted
Date Consumed (mm/dd/yyyy)
Commercial source
(e.g., store, restaurant)
Date Consumed (mm/dd/yyyy)
Farm-raised pig
Date Consumed (mm/dd/yyyy)
Wild pig
Date Consumed (mm/dd/yyyy)
Other pork
Did patient eat other meat (non-pork)?
If Yes, specify type of meat below.
 Yes
 No
 Unk
Type of Meat
Yes
No
Unk
If Yes, Specify as Noted
Date Consumed (mm/dd/yyyy)
Bear meat
Date Consumed (mm/dd/yyyy)
Hamburger (ground meat)
Type of Meat
Date Consumed (mm/dd/yyyy)
Other meat
Date Consumed (mm/dd/yyyy)
Unspecified meat
If patient reported eating any of the above meats, specify details below.
FOOD HISTORY - DETAILS
Type of Meat 1
Was the meat tested?
If tested, was evidence of larvae found?
 Yes
 No
 Unk
 Larvae identified
 Larvae not identified
 Unk
 Commercial source
 Pork from farm-raised pig
Where was the suspected meat obtained?
 Wild pig
 Direct from farm
 Hunted or trapped
 Restaurant or other public eating establishment
 Unk
 Other pork:_______________
 Butcher shop
 Supermarket / grocery store
 Other:_________________________________
 Bear meat
 Hamburger (ground meat)
How was the meat further processed?
 Other meat:______________
 No further processing
 Ground (i.e., hamburger)
 Smoked
 Other:_______________________
 Unspecified meat
 Dried (jerky)
 Marinated
 Unk
How was the meat prepared for consumption?
 Uncooked
 Fried
 Other cooking method:____________________
 Barbeque
 Open-fire roasting
 Unk
What was the final disposition of the suspected meat?
 Consumed
 Still in patient’s possession
 Disposed of with household waste
 Unk
 Given away or sold
 Cooked or otherwise processed
 Other:______________________
Type of Meat 2
Was the meat tested?
If tested, was evidence of larvae found?
 Yes
 No
 Unk
 Larvae identified
 Larvae not identified
 Unk
 Commercial source
 Pork from farm-raised pig
Where was the suspected meat obtained?
 Wild pig
 Direct from farm
 Hunted or trapped
 Restaurant or other public eating establishment
 Unk
 Other pork:_______________
 Butcher shop
 Supermarket / grocery store
 Other:_________________________________
 Bear meat
How was the meat further processed?
 Hamburger (ground meat)
 Other meat:______________
 No further processing
 Ground (i.e., hamburger)
 Smoked
 Other:_______________________
 Unspecified meat
 Dried (jerky)
 Marinated
 Unk
How was the meat prepared for consumption?
 Uncooked
 Fried
 Other cooking method:____________________
 Barbeque
 Open-fire roasting
 Unk
What was the final disposition of the suspected meat?
 Consumed
 Still in patient’s possession
 Disposed of with household waste
 Unk
 Given away or sold
 Cooked or otherwise processed
 Other:______________________
CDPH 8606 (revised 11/14)
Page 3 of 6
California Department of Public Health
TRICHINOSIS CASE REPORT
First three letters of
patient’s last name:
CONTACTS / OTHER ILL PERSONS
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)
Name 2
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)
NOTES / REMARKS
REPORTING AGENCY
Investigator Name
Local Health Jurisdiction
Telephone Number
Date (mm/dd/yyyy)
First Reported By
 Clinician
 Laboratory
 Other (specify):______________________
EPIDEMIOLOGICAL LINKAGE
Epi-linked to known case?
Contact Name / Case Number
 Yes
 No
 Unk
DISEASE CASE CLASSIFICATION
Case Classification (see case definition on page 5)
 Confirmed
 Probable
 Suspected
STATE USE ONLY
State Case Classification
 Confirmed
 Probable
 Suspected
 Not a case
 Need additional information
CDPH 8606 (revised 11/14)
Page 4 of 6
California Department of Public Health
TRICHINOSIS CASE REPORT
First three letters of
patient’s last name:
CASE DEFINITION
TRICHINOSIS (2014)
CLINICAL DESCRIPTION
A disease caused by ingestion of Trichinella larvae, usually through consumption of Trichinella-containing meat—or food contaminated with such meat—that
has been inadequately cooked prior to consumption. The disease has variable clinical manifestations. Common signs and symptoms among symptomatic
persons include eosinophilia, fever, myalgia, and periorbital edema.
LABORATORY CRITERIA FOR DIAGNOSIS
Human Specimens:
• Demonstration of Trichinella larvae in tissue obtained by biopsy, OR
• Positive serologic test for Trichinella
Food Specimens:
• Demonstration of Trichinella larvae in the food item (probable)
EPIDEMIOLOGIC LINKAGE
Persons who shared the implicated meat/meal should be investigated and considered for case status as described above.
CRITERIA TO DISTINGUISH A NEW CASE FROM AN EXISTING CASE
Serial or subsequent cases of trichinellosis experienced by one individual should only be counted if there is an additional epidemiologically compatible
exposure. Because the duration of antibodies to Trichinella spp. is not known, mere presence of antibodies without a clinically-compatible illness AND an
epidemiologically compatible exposure may not indicate a new infection especially among persons with frequent consumption of wild game that is known to
harbor the parasite.
CASE CLASSIFICATION
Suspected: Instances where there is no clinically compatible illness should be reported as suspect if the person shared an epidemiologically implicated
meal, or ate an epidemiologically implicated meat product, and has a positive serologic test for trichinellosis (and no known prior history of Trichinella
infection).
Probable:
• A clinically compatible illness in a person who shared an epidemiologically implicated meal or ate an epidemiologically implicated meat product, OR
• A clinically compatible illness in a person who consumed a meat product in which the parasite was demonstrated.
Confirmed: A clinically compatible illness that is laboratory confirmed in the patient.
COMMENTS
Epidemiologically implicated meals or meat products are defined as a meal or meat product that was consumed by a person who subsequently developed a
clinically compatible illness that was laboratory confirmed.
Negative serologic results may not accurately reflect disease status if blood was drawn less than 3-4 weeks from symptom onset (Wilson et. al, 2006).
REFERENCE
Wilson M, Schantz P, Nutman T, 2006. Molecular and immunological approaches to the diagnosis of parasitic infection. Detrick B, Hamilton RG, Folds JD,
eds. Manual of Molecular and Clinical Laboratory Immunology. Washington, DC: American Society for Microbiology, 557-568.
CDPH 8606 (revised 11/14)
Page 5 of 6