Form CDPH8586 "Typhoid and Paratyphoid Fever Case Report" - California

What Is Form CDPH8586?

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 January 1, 2012;
  • 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 CDPH8586 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form CDPH8586 "Typhoid and Paratyphoid Fever Case Report" - California

1454 times
Rate (4.8 / 5) 73 votes
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 fi nal 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
TYPHOID AND PARATYPHOID FEVER
CASE REPORT
Please complete this form only for new, symptomatic, culture-proven cases of typhoid or paratyphoid fever.
PATIENT INFORMATION
Last Name
First Name
Middle Name
Suffi x
Primary Language
English
Spanish
Years
Social Security Number (9 digits)
DOB (mm/dd/yyyy)
Age
Other:_____________________
Months
Days
Ethnicity (check one)
Hispanic/Latino
Address Number & Street - Residence
Apartment/Unit Number
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
Pacifi c 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
SIGNS AND SYMPTOMS
Was the patient ill with symptoms of typhoid or paratyphoid fever (sustained fever, headache,
If Yes, onset date of symptoms (mm/dd/yyyy)
anorexia, relative bradycardia, constipation or diarrhea, etc.)?
Yes No Unk
Date First Sought Medical Care (mm/dd/yyyy)
CDPH 8586 (revised 01/12)
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 fi nal 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
TYPHOID AND PARATYPHOID FEVER
CASE REPORT
Please complete this form only for new, symptomatic, culture-proven cases of typhoid or paratyphoid fever.
PATIENT INFORMATION
Last Name
First Name
Middle Name
Suffi x
Primary Language
English
Spanish
Years
Social Security Number (9 digits)
DOB (mm/dd/yyyy)
Age
Other:_____________________
Months
Days
Ethnicity (check one)
Hispanic/Latino
Address Number & Street - Residence
Apartment/Unit Number
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
Pacifi c 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
SIGNS AND SYMPTOMS
Was the patient ill with symptoms of typhoid or paratyphoid fever (sustained fever, headache,
If Yes, onset date of symptoms (mm/dd/yyyy)
anorexia, relative bradycardia, constipation or diarrhea, etc.)?
Yes No Unk
Date First Sought Medical Care (mm/dd/yyyy)
CDPH 8586 (revised 01/12)
Page 1 of 6
California Department of Public Health
TYPHOID AND PARATYPHOID FEVER CASE REPORT
First three letters of
patient’s last name:
PAST MEDICAL HISTORY
Did the patient receive typhoid vaccination (primary series
If Yes, indicate type of vaccine and year received below.
or booster) within fi ve years before onset of illness?
Oral Ty21a or Vivotif (Berna) four pill series?
Year Received (yyyy)
Yes No Unk
Yes No Unk
ViCPS or Typhin Vi shot (Pasteur Merieux)?
Year Received (yyyy)
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
OUTCOME
Outcome?
Date of Death (mm/dd/yyyy)
If Survived,
Survived Died Unk
Survived as of ________________________________(mm/dd/yyyy)
LABORATORY INFORMATION
LABORATORY RESULTS SUMMARY - FIRST ISOLATION
Date Salmonella First Isolated (mm/dd/yyyy)
Site(s) of Isolation:
Blood Stool Gall bladder Unk Other (specify):______________________
State Lab Isolate ID Number
Serotype
S. Typhi S. Paratyphi A S. Paratyphi B S. Paratyphi C Unk
Was antibiotic sensitivity testing performed on the (these) isolate(s) at the laboratory?
Yes No Unk
If Yes, specify if the organism was resistant to the antibiotics listed below.
Ampicillin?
Chloramphenicol?
Trimethoprim-sulfamethoxazole?
Fluoroquinolones (e.g. Ciprofl oxacin)?
Yes No Not tested Unk
Yes No Not tested Unk
Yes No Not tested Unk
Yes No Not tested Unk
CDPH 8586 (revised 01/12)
Page 2 of 6
California Department of Public Health
TYPHOID AND PARATYPHOID FEVER CASE REPORT
First three letters of
patient’s last name:
LABORATORY RESULTS SUMMARY - ADDITIONAL TESTS
Specimen Type 1
Type of Test
Collection Date (mm/dd/yyyy)
Results
Blood
Stool
Gall bladder
Unk
Laboratory Name
Telephone Number
Other:_______________
Specimen Type 2
Type of Test
Collection Date (mm/dd/yyyy)
Results
Blood
Stool
Gall bladder
Unk
Laboratory Name
Telephone Number
Other:_______________
Specimen Type 3
Type of Test
Collection Date (mm/dd/yyyy)
Results
Blood
Stool
Gall bladder
Unk
Laboratory Name
Telephone Number
Other:_______________
Specimen Type 4
Type of Test
Collection Date (mm/dd/yyyy)
Results
Blood
Stool
Gall bladder
Unk
Laboratory Name
Telephone Number
Other:_______________
EPIDEMIOLOGIC INFORMATION
INCUBATION PERIOD: 30 DAYS PRIOR TO ILLNESS ONSET
TRAVEL HISTORY
Did patient travel or live outside the United States
If Yes, date of most recent return or entry to the United States (mm/dd/yyyy)
during the incubation period?
If No, is patient a close personal contact of a
Describe
Yes No Unk
person who traveled internationally?
Yes No Unk
Did patient travel outside the county of residence during the incubation period?
Yes No Unk
If Yes, to either of the above travel questions, specify all locations and dates in the Travel History - Details table.
TRAVEL HISTORY - DETAILS
Location (city, county, state, country)
Date Travel Started (mm/dd/yyyy)
Date Travel Ended (mm/dd/yyyy)
EXPOSURES / RISK FACTORS
Did patient consume food or drink prepared outside of the home during
If Yes, specify name of place (e.g., restaurant, concession stand, friends
the incubation period?
house, etc.), location, date, and items consumed below.
Yes No Unk
EXPOSURES / RISK FACTOR - DETAILS
Name of Place 1
Location (city, state)
Date (mm/dd/yyyy)
Items Consumed
(continued on page 4)
CDPH 8586 (revised 01/12)
Page 3 of 6
California Department of Public Health
TYPHOID AND PARATYPHOID FEVER CASE REPORT
First three letters of
patient’s last name:
EXPOSURES / RISK FACTOR - DETAILS (continued)
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
ILL CONTACTS
Was the case traced to a typhoid carrier?
If Yes, was the carrier previously known to the health department?
Yes No Unk
Yes No Unk
Any contact with similar illness?
If there are any ill contacts or contacts who are typhoid carriers, list in the contact section 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
Occupation
Sensitive occupation / situation?
Yes No Unk
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
Occupation
Sensitive occupation / situation?
Yes No Unk
NOTES / REMARKS
CDPH 8586 (revised 01/12)
Page 4 of 6
California Department of Public Health
TYPHOID AND PARATYPHOID FEVER CASE REPORT
First three letters of
patient’s last name:
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?
Yes
No
Unk
DISEASE CASE CLASSIFICATION
Case Classifi cation (see case defi nition below)
Confirmed
Probable
OUTBREAK
Part of known outbreak?
If Yes, extent of outbreak
Yes No Unk
One CA jurisdiction
Multiple CA jurisdictions
Multistate
International
Unk
Other (specify):____________
Mode of Transmission
Vehicle of Outbreak
Pattern 1 ID number
Pattern 2 ID number
Point source
Person-to-person
Unk
Other:______________________
STATE USE ONLY
State Case Classifi cation
Confi rmed Probable Not a case Need additional information
CASE DEFINITION
TYPHOID FEVER (2010)
CLINICAL DESCRIPTION
An illness caused by Salmonella Typhi that is often characterized by insidious onset of sustained fever, headache, malaise, anorexia, relative bradycardia,
constipation or diarrhea, and nonproductive cough. However, many mild and atypical infections occur. Carriage of S. Typhi may be prolonged.
LABORATORY CRITERIA FOR DIAGNOSIS
Isolation of S. Typhi from blood, stool, or other clinical specimen
CASE CLASSIFICATION
- Probable: a clinically compatible case that is epidemiologically linked to a confi rmed case in an outbreak
- Confi rmed: a clinically compatible case that is laboratory confi rmed
COMMENT
Isolation of the organism is required for confi rmation. Serologic evidence alone is not suffi cient for diagnosis. Asymptomatic carriage should not be reported
as typhoid fever. Isolates of S. Typhi are reported to the Foodborne and Diarrheal Diseases Branch, Division of Bacterial and Mycotic Diseases, National
Center for Infectious Diseases, CDC, through the Public Health Laboratory Information System.
CDPH 8586 (revised 01/12)
Page 5 of 6