Form CDPH8563 "Typhoid Carrier Agreement" - California

What Is Form CDPH8563?

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 July 1, 2007;
  • 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 CDPH8563 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 CDPH8563 "Typhoid Carrier Agreement" - California

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California Department of Public Health
State of California—Health and Human Services Agency
Surveillance & Statstics Section
P.O. Box 997377, MS 7306
Sacramento CA 95899-7377
TYPHOID CARRIER AGREEMENT
I have been informed that I am a typhoid carrier and that unless precautions are taken, persons may contract typhoid fever from
me. Realizing this danger, I hereby agree to observe the precautions stated below:
1. I shall take no part in the preparation, serving, or handling of milk or other food which may be consumed by any person
other than members of my own immediate family.
2. I shall not participate in the management of a dairy or other milk distributing plant, boarding house, restaurant, food store,
or any place where food is prepared or served, nor engage in any occupation involving the preparation or handling of
food. I shall encourage the members of my family to be immunized against typhoid fever, if recommended by the local
health officer.
3. I shall not engage in any occupation involving the direct care of young children, the elderly, or patients in hospitals or
other institutional settings.
4. I shall wash my hands thoroughly with soap and hot water after using the toilet and before handling food 100 percent of
the time.
5. If flush toilets are not available, I shall dispose of my stool and urine according to the instructions given me by the local
health officer to prevent access of flies and/or contamination of drinking water.
6. I shall report immediately to the local health officer any case of illness suggestive of typhoid in my family or associates.
7. I shall inform the local health officer of any contemplated change of address or occupation so that she/he can notify the
California Department of Public Health.
8. I shall communicate with the local health officer before submitting to any type of treatment intended to cure the typhoid
carrier state.
9. I shall notify any physician, hospital, or other institution providing medical care to me, of my carrier condition.
10. The health officer may inform any physician, hospital, or other institution providing my medical care, of otherwise
confidential details regarding my carrier condition.
I understand that this information is confidential and will not be divulged unless I violate the terms of this agreement and/or
action becomes necessary to protect the public .
__________________________________________________
_____________________________________________
Name of typhoid carrier (print)
First
Last
Signature of typhoid carrier
Date
__________________________________________________
_____________________________________________
Address (number, street)
City
State
Zip code
Witnesses:
__________________________________________________
_____________________________________________
Name of witness (print)
First
Last
Signature
Date
__________________________________________________
_____________________________________________
Name of witness (print)
First
Last
Signature
Date
CDPH 8563 (7/07) (Department and address updated. This replaces 5/99 version.)
CDPH 8563 (7/07) (Department and address updated. This replaces 5/99 version.)
California Department of Public Health
State of California—Health and Human Services Agency
Surveillance & Statstics Section
P.O. Box 997377, MS 7306
Sacramento CA 95899-7377
TYPHOID CARRIER AGREEMENT
I have been informed that I am a typhoid carrier and that unless precautions are taken, persons may contract typhoid fever from
me. Realizing this danger, I hereby agree to observe the precautions stated below:
1. I shall take no part in the preparation, serving, or handling of milk or other food which may be consumed by any person
other than members of my own immediate family.
2. I shall not participate in the management of a dairy or other milk distributing plant, boarding house, restaurant, food store,
or any place where food is prepared or served, nor engage in any occupation involving the preparation or handling of
food. I shall encourage the members of my family to be immunized against typhoid fever, if recommended by the local
health officer.
3. I shall not engage in any occupation involving the direct care of young children, the elderly, or patients in hospitals or
other institutional settings.
4. I shall wash my hands thoroughly with soap and hot water after using the toilet and before handling food 100 percent of
the time.
5. If flush toilets are not available, I shall dispose of my stool and urine according to the instructions given me by the local
health officer to prevent access of flies and/or contamination of drinking water.
6. I shall report immediately to the local health officer any case of illness suggestive of typhoid in my family or associates.
7. I shall inform the local health officer of any contemplated change of address or occupation so that she/he can notify the
California Department of Public Health.
8. I shall communicate with the local health officer before submitting to any type of treatment intended to cure the typhoid
carrier state.
9. I shall notify any physician, hospital, or other institution providing medical care to me, of my carrier condition.
10. The health officer may inform any physician, hospital, or other institution providing my medical care, of otherwise
confidential details regarding my carrier condition.
I understand that this information is confidential and will not be divulged unless I violate the terms of this agreement and/or
action becomes necessary to protect the public .
__________________________________________________
_____________________________________________
Name of typhoid carrier (print)
First
Last
Signature of typhoid carrier
Date
__________________________________________________
_____________________________________________
Address (number, street)
City
State
Zip code
Witnesses:
__________________________________________________
_____________________________________________
Name of witness (print)
First
Last
Signature
Date
__________________________________________________
_____________________________________________
Name of witness (print)
First
Last
Signature
Date
CDPH 8563 (7/07) (Department and address updated. This replaces 5/99 version.)
CDPH 8563 (7/07) (Department and address updated. This replaces 5/99 version.)