Form CDPH8559 "Tularemia Case Report" - California

What Is Form CDPH8559?

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 CDPH8559 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 CDPH8559 "Tularemia 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
TULAREMIA
CASE REPORT
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 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 8559 (revised 04/11)
Page 1 of 7
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
TULAREMIA
CASE REPORT
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 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 8559 (revised 04/11)
Page 1 of 7
California Department of Public Health
TULAREMIA 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
Location
Cutaneous ulcer
Location
Other skin lesion
Location
Lymphadenopathy
Sepsis
Pharyngitis
Pleuropneumonia
Cough
Conjunctivitis
Stomatitis
Tonsilitis
Abdominal pain
Vomiting
Diarrhea
Other signs / symptoms (specify)
PAST MEDICAL HISTORY
Mucous membrane/skin cut or abrasion?
If Yes, specify location
Yes No Unk
Immunocompromised?
If Yes, specify condtion
Yes No Unk
Other (specify)
CDPH 8559 (revised 04/11)
Page 2 of 7
California Department of Public Health
TULAREMIA 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
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
OUTCOME
Outcome?
If Survived,
Date of Death (mm/dd/yyyy)
Survived as of ________________________________(mm/dd/yyyy)
Survived Died Unk
LABORATORY INFORMATION
LABORATORY RESULTS SUMMARY
Specimen Type 1
Type of Test
Collection Date
(mm/dd/yyyy)
Biopsy or scraping of ulcer
ELISA Immunofluorescence antibody
Blood
Culture
PCR
Swab of ulcer
Tissue aspirate
Agglutination CF
DFA
Other:___________________
Serum (acute) IgM
Serum (convalescent) IgM
Result
Specify (if applicable)
Interpretation
Serum (acute) IgG
Serum (convalescent) IgG
Result Unit:
Titer
O.D.
Positive
Equivocal
IsolateOther:_________________
Result Type:
DNA
mRNA
Negative
If Serum (acute) is submitted, then Serum
Laboratory Name
Telephone Number
(convalescent) must also be submitted.
Specimen Type 2
Type of Test
Collection Date
(mm/dd/yyyy)
Biopsy or scraping of ulcer
ELISA Immunofluorescence antibody
Blood
Culture
PCR
Swab of ulcer
Tissue aspirate
Agglutination CF
DFA
Other:___________________
Serum (acute) IgM
Serum (convalescent) IgM
Result
Specify (if applicable)
Interpretation
Serum (acute) IgG
Serum (convalescent) IgG
Result Unit:
Titer
O.D.
Positive
Equivocal
Isolate
Other:_________________
Result Type:
DNA
mRNA
Negative
If Serum (acute) is submitted, then Serum
Laboratory Name
Telephone Number
(convalescent) must also be submitted.
CDPH 8559 (revised 04/11)
Page 3 of 7
California Department of Public Health
TULAREMIA CASE REPORT
First three letters of
patient’s last name:
LABORATORY RESULTS SUMMARY - OTHER
Was the biotype identified?
If Yes, specify biotype
Laboratory Name
Telephone Number
Type A Type B Other______________
Yes No Unk
IMAGING SUMMARY
Anatomic Site 1
Type of Imaging
Date (mm/dd/yyyy)
X-ray
CT
MRI
Other:_________________
Result
Interpretation
Facility Name
Telephone Number
Anatomic Site 2
Type of Imaging
Date (mm/dd/yyyy)
X-ray
CT
MRI
Other:_________________
Result
Interpretation
Facility Name
Telephone Number
EPIDEMIOLOGIC INFORMATION
INCUBATION PERIOD: 3 WEEKS 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
Animal species and meat product
Undercooked meat
Location
Untreated water
Other (specify)
OCCUPATIONAL / RECREATIONAL EXPOSURE
DID THE PATIENT EXPERIENCE ANY OF THE FOLLOWING EVENTS OR OCCUPATIONS DURING THE INCUBATION PERIOD?
Event / Occupation
Yes
No
Unk
If Yes, Specify as Noted
Address where tick contact occurred
Known tick contact
Address where deerfly contact occurred
Known deerfly contact
Location
Contact with untreated water
Laboratory name and location
Microbiology laboratory
Animal species and location
Veterinary medicine
Animal species and location
Farmer / livestock owner
Animal species and location
Hunting / animal trapping / fishing
Location
Landscape / gardening
Location
Hiking / camping
Other (specify)
CDPH 8559 (revised 04/11)
Page 4 of 7
California Department of Public Health
TULAREMIA CASE REPORT
First three letters of
patient’s last name:
ANIMAL EXPOSURES
DID THE PATIENT HAVE CONTACT WITH ANY OF THE FOLLOWING ANIMALS DURING THE INCUBATION PERIOD?
Animal Exposures
Yes
No
Unk
If Yes, Specify as Noted
Species
Contact type(s)
Wild rabbit
Handling Skinning Bite Other:____________________
Breed
Contact type(s)
Domestic rabbit
Handling Skinning Bite Other:____________________
Species
Contact type(s)
Wild rodent
Handling Skinning Bite Other:____________________
Species
Contact type(s)
Domestic rodent
Handling Skinning Bite Other:____________________
Species
Contact type(s)
Other wild animal(s)
Handling Skinning Bite Other:____________________
Species
Contact type(s)
Other domestic animal(s)
Handling Skinning Bite Other:____________________
TRAVEL HISTORY (INCUBATION PERIOD IS 7 DAYS PRIOR TO ILLNESS ONSET)
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
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)
CDPH 8559 (revised 04/11)
Page 5 of 7