Form CDPH8299 "' varicella (Chicken Pox) Hospitalized Case Report" - California

What Is Form CDPH8299?

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, 2016;
  • The latest edition provided by the California Department of Public Health;
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  • Fill out the form in our online filing application.

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Download Form CDPH8299 "' varicella (Chicken Pox) Hospitalized Case Report" - California

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California Dept. of Public Health
VARICELLA (CHICKEN POX) HOSPITALIZED CASE REPORT
Immunization Branch
850 Marina Bay Parkway
nd
Building P, 2
Floor, MS 7313
Richmond, CA 94804-6403
PATIENT DEMOGRAPHICS
Patient’s name (last, first, middle initial)
DOB (month /day /year)
Age (enter age and check one)
/
/
Days
Weeks
Months
Years
Address (number and street)
City/town
State
Zip code
County
Country of birth
Date of arrival to USA
Gender
F
M
FTM
MTF
Other
Unknown
/
/
Other Specify
Unknown
USA
Race (check all that apply)
Black/African American
Asian (please specify)
Pacific Islander (please specify)
Native American/Alaskan
Asian Indian
Hmong
Thai
Native Hawaiian
White
Cambodian
Japanese
Vietnamese
Guamanian
Unknown
Chinese
Korean
Other Asian
Samoan
Other
Filipino
Laotian
Other Pacific Islander
Ethnicity (check one)
Hispanic/Latino
Non-Hispanic/Non-Latino
Unknown
Occupation Setting (check all that apply)
Occupation
Health Care
Day Care
School
Correctional Facility
Other, specify:
COMMON LHD TRACKING DATA
CMRID number
IZB case ID number
Reporter telephone
Date reported to county
Date investigation started
Person/clinician reporting case
(
)
/
/
/
/
Investigator telephone
Case investigator completing form
Investigator jurisdiction
(
)
CLINICAL INFO: SIGNS AND SYMPTOMS
Rash onset
Diagnosis date
Physician diagnosis (select only one)
Maculo-papulovesicular rash
/
/
/
/
Yes
No
Unknown
Chickenpox
Shingles (If shingles, not reportable)
Unknown
Total number of lesions
Spread of rash
Rash characteristics (check all that apply)
Unknown
Mild (<50 lesions)
Generalized rash
Painful
Tingling or numbness
Itchy
Mild/moderate (50-249 lesions)
Localized rash (1-3 dermatomes)
Lesions present in different stages (vesicles, crusted lesions)
Unknown
Moderate (250-499 lesions)
Severe (>500 lesions or complications)
Fever>100.4
Yes
No
Unknown
Location
Yes
No
Unknown
Describe:
Other symptoms
Duration of rash
Yes
No
DOES CASE MEET CSTE CLINICAL CRITERIA?
Unknown
HOSPITALIZATION/COMPLICATIONS AND OTHER SYMPTOMS
Reasons for hospitalization (check all that apply)
Hospitalized (>24 hours)
Total nights hospitalized
Unknown
No
Yes
Unknown
Varicella-related complication
Administration of IV treatment
Severity
/
/
/ /
Admission date
Discharge date
Non-varicella hospitalization
Other, specify
Isolation
__________
Observation
with coincident varicella
Name of hospital
Cerebellitis/Ataxia
Skin/soft tissue infection
Complications
Secondary bacterial infection?
Encephalitis
Yes
No
No
No
No
Unknown
Yes
Yes
Unknown
Yes
Unknown
Unknown
Yes
No
Unknown
If yes, specify
Hemorrhagic condition
Meningitis
Dehydration/hypovolemia
Pneumonia
Death (If yes, complete worksheet)
No
No
Yes
No
Unknown
Date
Yes
Unknown
Yes
Unknown
Yes
No
Unknown
/
/
No
Specify other complications
Yes
Unknown
VACCINATION / MEDICAL HISTORY
Number of
Dates of vaccination
Dose 3
Received one or more doses of
doses
varicella containing vaccine
Dose 1
Dose 2
/
/
Date Unknown
prior to
No
Dose 4
Yes, self-reported
illness
/
/
Date Unknown
/
Date Unknown
/
Unknown
Yes, documented
onset
Date Unknown
/
/
Comments-specify co-morbidities, reason for
Reason for not being vaccinated
Prior MD diagnosis of varicella
Yes
No
Unknown
immunocompromised status (list medications
(check all that apply)
Prior MD diagnosis of shingles
Yes
or conditions) and type of antiviral treatment
No
Unknown
Personal Beliefs Exemption (PBE)
Immunocompromised
Yes
No
Unknown
Permanent Medical Exemption (PME)
( If yes, explain in comments)
Temporary Medical Exemption
Pregnant
Yes
No
Unknown
Lab confirmation of previous disease
If yes, estimated delivery date
/
/
MD diagnosis of previous disease
Co-morbidities
Under age for vaccination
Yes
No
(If yes, specify in comments)
Unknown
Delay in starting series or between doses
Antivirals taken
Unknown
Yes
No
Unknown
Other
( If yes, specify in comments)
Page 1 of 2
CDPH 8299 (11/16)
California Dept. of Public Health
VARICELLA (CHICKEN POX) HOSPITALIZED CASE REPORT
Immunization Branch
850 Marina Bay Parkway
nd
Building P, 2
Floor, MS 7313
Richmond, CA 94804-6403
PATIENT DEMOGRAPHICS
Patient’s name (last, first, middle initial)
DOB (month /day /year)
Age (enter age and check one)
/
/
Days
Weeks
Months
Years
Address (number and street)
City/town
State
Zip code
County
Country of birth
Date of arrival to USA
Gender
F
M
FTM
MTF
Other
Unknown
/
/
Other Specify
Unknown
USA
Race (check all that apply)
Black/African American
Asian (please specify)
Pacific Islander (please specify)
Native American/Alaskan
Asian Indian
Hmong
Thai
Native Hawaiian
White
Cambodian
Japanese
Vietnamese
Guamanian
Unknown
Chinese
Korean
Other Asian
Samoan
Other
Filipino
Laotian
Other Pacific Islander
Ethnicity (check one)
Hispanic/Latino
Non-Hispanic/Non-Latino
Unknown
Occupation Setting (check all that apply)
Occupation
Health Care
Day Care
School
Correctional Facility
Other, specify:
COMMON LHD TRACKING DATA
CMRID number
IZB case ID number
Reporter telephone
Date reported to county
Date investigation started
Person/clinician reporting case
(
)
/
/
/
/
Investigator telephone
Case investigator completing form
Investigator jurisdiction
(
)
CLINICAL INFO: SIGNS AND SYMPTOMS
Rash onset
Diagnosis date
Physician diagnosis (select only one)
Maculo-papulovesicular rash
/
/
/
/
Yes
No
Unknown
Chickenpox
Shingles (If shingles, not reportable)
Unknown
Total number of lesions
Spread of rash
Rash characteristics (check all that apply)
Unknown
Mild (<50 lesions)
Generalized rash
Painful
Tingling or numbness
Itchy
Mild/moderate (50-249 lesions)
Localized rash (1-3 dermatomes)
Lesions present in different stages (vesicles, crusted lesions)
Unknown
Moderate (250-499 lesions)
Severe (>500 lesions or complications)
Fever>100.4
Yes
No
Unknown
Location
Yes
No
Unknown
Describe:
Other symptoms
Duration of rash
Yes
No
DOES CASE MEET CSTE CLINICAL CRITERIA?
Unknown
HOSPITALIZATION/COMPLICATIONS AND OTHER SYMPTOMS
Reasons for hospitalization (check all that apply)
Hospitalized (>24 hours)
Total nights hospitalized
Unknown
No
Yes
Unknown
Varicella-related complication
Administration of IV treatment
Severity
/
/
/ /
Admission date
Discharge date
Non-varicella hospitalization
Other, specify
Isolation
__________
Observation
with coincident varicella
Name of hospital
Cerebellitis/Ataxia
Skin/soft tissue infection
Complications
Secondary bacterial infection?
Encephalitis
Yes
No
No
No
No
Unknown
Yes
Yes
Unknown
Yes
Unknown
Unknown
Yes
No
Unknown
If yes, specify
Hemorrhagic condition
Meningitis
Dehydration/hypovolemia
Pneumonia
Death (If yes, complete worksheet)
No
No
Yes
No
Unknown
Date
Yes
Unknown
Yes
Unknown
Yes
No
Unknown
/
/
No
Specify other complications
Yes
Unknown
VACCINATION / MEDICAL HISTORY
Number of
Dates of vaccination
Dose 3
Received one or more doses of
doses
varicella containing vaccine
Dose 1
Dose 2
/
/
Date Unknown
prior to
No
Dose 4
Yes, self-reported
illness
/
/
Date Unknown
/
Date Unknown
/
Unknown
Yes, documented
onset
Date Unknown
/
/
Comments-specify co-morbidities, reason for
Reason for not being vaccinated
Prior MD diagnosis of varicella
Yes
No
Unknown
immunocompromised status (list medications
(check all that apply)
Prior MD diagnosis of shingles
Yes
or conditions) and type of antiviral treatment
No
Unknown
Personal Beliefs Exemption (PBE)
Immunocompromised
Yes
No
Unknown
Permanent Medical Exemption (PME)
( If yes, explain in comments)
Temporary Medical Exemption
Pregnant
Yes
No
Unknown
Lab confirmation of previous disease
If yes, estimated delivery date
/
/
MD diagnosis of previous disease
Co-morbidities
Under age for vaccination
Yes
No
(If yes, specify in comments)
Unknown
Delay in starting series or between doses
Antivirals taken
Unknown
Yes
No
Unknown
Other
( If yes, specify in comments)
Page 1 of 2
CDPH 8299 (11/16)
VARICELLA (CHICKEN POX) HOSPITALIZED CASE REPORT
California Dept. of Public Health
Immunization Branch
850 Marina Bay Parkway
nd
Building P, 2
Floor, MS 7313
Richmond, CA 94804-6403
LABORATORY INFO
Name of diagnostic laboratory
CASE LAB CONFIRMED (FOR STATE USE ONLY)
Yes
No
Unknown
DFA performed:
Source
DFA specimen date
DFA result
LAB RESULT CODES
Yes
No
Unknown
/
/
P
N
I
E
X
U
P = Positive
N = Negative
PCR performed
Source
PCR specimen date
PCR result
(antibody not detected)
Yes
No
Unknown
/
/
P
N
I
E
X
U
I = Indeterminate
Virus isolation performed
Source
Virus specimen date
Virus isolated
E = Pending
Yes
No
Unknown
/
/
Yes
No
Unknown
X = Not done
U = Unknown
Genotyping performed
Date sent
Genotype
Yes
No
Unknown
/
/
Serology performed
Yes
No
Unknown
Specimen date
Titer result
Test reference index
Result interpretation
IgM
P
N
I
E
X
U
/
/
IgG (acute)
/
/
P
N
I
E
X
U
IgG (convalescent)
P
N
I
E
X
U
/
/
Other lab tests performed
Source
Other lab test date
Specify lab tests
Other lab test results
Yes
No
Unknown
/
/
Source
Other lab test results
Specify lab tests
Other lab test date
/
/
EPIDEMIOLOGIC INFO:
Please report all contacts meeting the probable or confirmed case definitions on a separate Case Report Form.
Close contact with person(s) with rash OR shingles (zoster) 10-21 days before rash onset
Yes
No
Unknown
Epi-linked to a lab-confirmed or probable case
Outbreak related
Outbreak name or location
Yes
No
Unknown If yes, Name or Case ID:
Yes
No
Unknown
SPREAD SETTING (check all that apply)
Day care
Hospital Ward
Home
Military
Unknown
School
Hospital ER
Work
Correctional facility
Other
Doctor’s office
Outpatient hospital clinic
College
Church
Close contacts who have rash 10-21 days after exposure to case
Yes
No
Unknown
Number of susceptible contacts
Same
Pregnant
Estimated
household
Name
Rash onset
(Select one)
date of delivery
Age (years)
(Select one)
Prophylaxis
Y
N
U
Y
N
U
VariZIG
Vaccination
None
/
/
/
/
1
/
/
Y
N
U
/
/
Y
N
U
VariZIG
Vaccination
None
2
/
/
Y
N
U
/
/
Y
N
U
VariZIG
Vaccination
None
3
Please list other contacts on a separate sheet or use the contact tracing worksheet.
CASE CLASSIFICATION (FOR LHD USE)
CASE CLASSIFICATION (FOR STATE USE ONLY)
Confirmed
Probable
Not a case
Unknown
Confirmed
Probable
Not a case
Unknown
VARICELLA (chickenpox) 2010 CASE DEFINITION
CSTE Position Statement Number: 09-ID-68
Clinical Case Definition: An illness with acute onset of diffuse (generalized) maculo-papulovesicular rash without other apparent cause.
Case Classification:
Probable:
An Acute illness with diffuse (generalized) maculo-papulovesicular rash, AND lack of laboratory confirmation, AND lack of epidemiologic
linkage to another probable or confirmed case.
Confirmed: An acute illness with diffuse (generalized) maculo-papulovesicular rash, AND epidemiologic linkage to another probable or confirmed case,
OR
Laboratory confirmation (criteria for diagnosis) by any of the following:
-Isolation of varicella virus from a clinical specimen, OR
-Varicella antigen detected by direct fluorescent antibody test, OR
-Varicella-specific nucleic acid detected by polymerase chain reaction (PCR), OR
-Significant rise in serum anti-varicella immunoglobulin G (IgG) antibody level by any standard serologic assay.
CDPH 8299 (11/16)
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