Form CDPH9063 "California Syphilis Interview Record" - California

What Is Form CDPH9063?

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 June 1, 2010;
  • 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 CDPH9063 "California Syphilis Interview Record" - California

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State of California—Health and Human Services Agency
California Department of Public Health
CALIFORNIA SYPHILIS INTERVIEW RECORD
Interview Record ID
STAGE OF SYPHILIS
Lot #:
Neurosyphilis?
P
S
N
Neurologic Symptoms?
C
U
Y
N
U
Working:
PHONE / CONTACT
Final:
Current Co-Infections?
1) _______
2) _______
3) _______
N
U
Home Phone
Last Name
First Name
Middle Initial
Work Phone
Preferred Name / AKA
Maiden Name
Cellular Phone/Pager
E-mail Address/Chatroom & ID #1
Time
Residence Street
(Apt. #)
at Address?
E-mail Address/Chatroom & ID #2
U
W
M
Y
in State?
U
W
M
Y
City
Zip
Emergency Contact Name
In U.S.?
U
W
M
Y
Emergency Contact Relationship
Jurisdiction/County name (State/Country if non-CA case)
Census Tract
Living With:
Emergency Contact Phone
Colonia/District (Bi-national only)
Relationship:
House/Condo
Apartment
Dorm
Homeless
Hotel/Motel
Unknown
Residence Type:
Institution (if checked, complete the section below)
Migrant Camp
Group Home
Other: _______________________
U
Institutionalized at diagnosis?
If Yes, Jurisdiction #: _______
Since when: ______________
Institution ID #: _____________________
Y
N
Facility Name: ____________________________________
Type Facility:
Juvenile Det.
Jail
Prison
Mental Health
Drug Treatment/Rehab
Hispanic/
Race
W
B
A
NH/PI
AI/AN
U
O
Y
N
U
Latino?
(Select All
Age
(Please Specify Other)
Date of Birth
That Apply)
M
F
U
Gender at birth:
Marital Status:
Patient has sex with: (check all that apply)
S
M
C
D
Sep
W
U
Male
Female
MTF
FTM
Unknown
M
F
MTF
FTM
U
Current Gender:
Y
N
U
Y
N
U
FEMALES ONLY: Currently pregnant?
If Yes, No. of weeks: ______
Currently in prenatal care?
Y
N
U
D
S
M
A
U
Other pregnancy in last 12 months?
Date of outcome: ______________
U
If Yes, outcome:
Via (check only one):
Date of Specimen Collection:
________________
Date Provider First
Telephone call/referral from PMD
_____________
Reported/Contacted:
CMR from PMD
Date Lab Report received:
No lab report rec’d
________________
DIS/Public Health staff contacted PMD
Was this case initially reported to or interviewed in another jurisdiction?
No
Rpt
Ix
Date case was received /
_____________
DIS: _______
re-assigned in LHJ:
If reported or interviewed elsewhere, Jurisdiction #: ________
Jurisdiction # of Responsibility:
________
Date case was first assigned:
_____________
DIS: _______
Date assigned for re-interview:
_____________
DIS: _______
Date of original interview:
_____________
DIS: _______
Date of re-interview:
_____________
DIS: _______
Type of original interview:
No interview (complete reason below)
BASIS FOR EARLY STAGE – complete at case closure
Clinic
Field
Telephone
Jail / Prison
Internet
Lesion Present
History, Past 12 Months (730 dx only)
IF NOT INTERVIEWED, REASON: (check one only)
(710 dx only)
(check all that apply below)
Declined Interview
Negative STS
4-Fold Titer Increase
Secondary
Incarceration Barrier
Describe: _____________________________
Symptoms Present
Exposure to Independently
P&S Symptoms
Language Barrier
Identify language: ______________________
(720 dx only)
Confirmed Early Infection
Bad/no locating information
No basis, late diagnosis
Correct locating information; no patient response
Initial contact made; no interview
Other: _________________________________________________
DIS
Sup
Date Case Closed
A
B
C
Local Use:
Page 1 of 9
CDPH 9063 (06/10) - CA Syphilis IR (11/3/2009)
State of California—Health and Human Services Agency
California Department of Public Health
CALIFORNIA SYPHILIS INTERVIEW RECORD
Interview Record ID
STAGE OF SYPHILIS
Lot #:
Neurosyphilis?
P
S
N
Neurologic Symptoms?
C
U
Y
N
U
Working:
PHONE / CONTACT
Final:
Current Co-Infections?
1) _______
2) _______
3) _______
N
U
Home Phone
Last Name
First Name
Middle Initial
Work Phone
Preferred Name / AKA
Maiden Name
Cellular Phone/Pager
E-mail Address/Chatroom & ID #1
Time
Residence Street
(Apt. #)
at Address?
E-mail Address/Chatroom & ID #2
U
W
M
Y
in State?
U
W
M
Y
City
Zip
Emergency Contact Name
In U.S.?
U
W
M
Y
Emergency Contact Relationship
Jurisdiction/County name (State/Country if non-CA case)
Census Tract
Living With:
Emergency Contact Phone
Colonia/District (Bi-national only)
Relationship:
House/Condo
Apartment
Dorm
Homeless
Hotel/Motel
Unknown
Residence Type:
Institution (if checked, complete the section below)
Migrant Camp
Group Home
Other: _______________________
U
Institutionalized at diagnosis?
If Yes, Jurisdiction #: _______
Since when: ______________
Institution ID #: _____________________
Y
N
Facility Name: ____________________________________
Type Facility:
Juvenile Det.
Jail
Prison
Mental Health
Drug Treatment/Rehab
Hispanic/
Race
W
B
A
NH/PI
AI/AN
U
O
Y
N
U
Latino?
(Select All
Age
(Please Specify Other)
Date of Birth
That Apply)
M
F
U
Gender at birth:
Marital Status:
Patient has sex with: (check all that apply)
S
M
C
D
Sep
W
U
Male
Female
MTF
FTM
Unknown
M
F
MTF
FTM
U
Current Gender:
Y
N
U
Y
N
U
FEMALES ONLY: Currently pregnant?
If Yes, No. of weeks: ______
Currently in prenatal care?
Y
N
U
D
S
M
A
U
Other pregnancy in last 12 months?
Date of outcome: ______________
U
If Yes, outcome:
Via (check only one):
Date of Specimen Collection:
________________
Date Provider First
Telephone call/referral from PMD
_____________
Reported/Contacted:
CMR from PMD
Date Lab Report received:
No lab report rec’d
________________
DIS/Public Health staff contacted PMD
Was this case initially reported to or interviewed in another jurisdiction?
No
Rpt
Ix
Date case was received /
_____________
DIS: _______
re-assigned in LHJ:
If reported or interviewed elsewhere, Jurisdiction #: ________
Jurisdiction # of Responsibility:
________
Date case was first assigned:
_____________
DIS: _______
Date assigned for re-interview:
_____________
DIS: _______
Date of original interview:
_____________
DIS: _______
Date of re-interview:
_____________
DIS: _______
Type of original interview:
No interview (complete reason below)
BASIS FOR EARLY STAGE – complete at case closure
Clinic
Field
Telephone
Jail / Prison
Internet
Lesion Present
History, Past 12 Months (730 dx only)
IF NOT INTERVIEWED, REASON: (check one only)
(710 dx only)
(check all that apply below)
Declined Interview
Negative STS
4-Fold Titer Increase
Secondary
Incarceration Barrier
Describe: _____________________________
Symptoms Present
Exposure to Independently
P&S Symptoms
Language Barrier
Identify language: ______________________
(720 dx only)
Confirmed Early Infection
Bad/no locating information
No basis, late diagnosis
Correct locating information; no patient response
Initial contact made; no interview
Other: _________________________________________________
DIS
Sup
Date Case Closed
A
B
C
Local Use:
Page 1 of 9
CDPH 9063 (06/10) - CA Syphilis IR (11/3/2009)
State of California—Health and Human Services Agency
California Department of Public Health
Interview Record ID
CLINICAL/LAB INFORMATION
Reporting Provider Name
Facility Name
City
State
Method of Case Detection?
Type of Facility where patient was INITIALLY tested (or test was ordered) for syphilis?
99-Unknown
(check only one)
(check only one main category)
1-Categorical STD Clinic
10-Emergency Dept.
20-Juvenile Detention
Self-referred (check one)
2-HIV Care
11-Urgent Care
21-Jail
Syphilis symptoms
Other STD symptoms
3-HIV Counseling & Testing
12-Local Public Health Clinic
22-Prison
High risk (asymptomatic)
4-Early Intervention Program (EIP)
13-Community Health Clinic
23-Military
Screening
5-Women’s Health/GYN Practice
14-Community Based Organization
24-Field Blood – individual draw
Patient Referred Partner
6-Prenatal
15-Migrant Health Clinic
25-Field Blood – Health Dept Screening
Health Department Referred Partner
7-Labor & Delivery
16-Primary Care/Intern. Med/Family Practice
26-Sex Venue
Cluster Related/Sexual Network
8-Hospital Inpatient
17-Family Planning/Planned Parenthood
27-Blood Bank
9-Hospital Outpatient
28-Mobile Clinic
18-Indian Health Services
OP Interview Record ID
19-Drug Treatment Facility
88-Other: _______________________
OP Lot #
OP Dx
Name of Facility/Provider
Date: ________________
who ordered test: _________________________________________________________
Name of Facility/Provider where exam took place:
Clinical Syphilis Diagnosis
Clinician Observed
No exam
Y
N
U
Syphilis Signs?
Primary
___________________________________________________________
Symptom
Observation
Anatomic
Facility
Code
Date
Site
Secondary
Type
Date of Physical Exam: ________________
1.
Early Latent
Clinical evaluation data collected from provider via: (check all that apply)
Late Latent
2.
CMR
Provider Interview
Latent, Unknown Duration
3.
Fax Back
Chart Review by Public Health Staff
Stage Unknown/No diagnosis
Neurosyphilis
If Symptom Code = X or O, OR Anatomic Site = O, specify
Reporting Laboratory Name
City
State
Historical, Screening, Treatment, and Follow-up Serologies, and Other Testing for Current Diagnosis
Quantitative
Qualitative
(Non-Trep)
Quantitative
(Treponemal)
Qualitative
Date Collected
Requesting Facility
Laboratory Name
Test
Result
Test
Result
P
N
I
U
Last Neg. STS:
XXXXX
P
N
I
U
Last Pos. STS:
P
N
I
U
S
T
F
P
N
I
U
S
T
F
S
T
F
P
N
I
U
P
N
I
U
S
T
F
Drug/Dosage #1 (select one drug only)
N
T
OT
REATED
Doxycycline 100 mg po bid
Benzathine penicillin G 2.4 mu
Tetracycline 500 mg po qid
x1
x2
x3
Other: ___________
14 days
28 days
_______ days
14 days
28 days
_______ days
Ceftriaxone
1g IM/IV
2g IM/IV
Other: _________
Crystalline penicillin G 3-4 mu, IV Q4 hr
Other: ___________________________________
8-10 days
________ days
10-14 days
________ days
(include drug, dose, and duration)
RX Date #1
RX Date #2
RX Date #3
Facility/Provider
Facility Type
Drug/Dosage #2 (select one drug only)
Doxycycline 100 mg po bid
Benzathine penicillin G 2.4 mu
Tetracycline 500 mg po qid
x1
x2
x3
Other: ___________
14 days
28 days
_______ days
14 days
28 days
_______ days
Ceftriaxone
1g IM/IV
2g IM/IV
Other: _________
Crystalline penicillin G 3-4 mu, IV Q4 hr
Other: ___________________________________
8-10 days
________ days
10-14 days
________ days
(include drug, dose, and duration)
RX Date #1
RX Date #2
RX Date #3
Facility/Provider
Facility Type
Page 2 of 9
CDPH 9063 (06/10) - CA Syphilis IR (11/3/2009)
State of California—Health and Human Services Agency
California Department of Public Health
PATIENT INFORMATION
Interview Record ID
(Information on this page can be obtained from the patient OR provider/medical record)
Frequency of US-Mexico Border Crossing:
Country of birth:
R
R
1 time
At least 1 time
Few times
Every 2-3
USA
Mexico
Other: __________________
Daily/weekly
Rarely
Never
per month
per year
per year
years
Primary language:
R
Occupation/Means of Support:
Code
Other: _________________
English
Spanish
Describe
Patient Described
Y
N
R
Y
N
R
If Yes, did you previously seek care for any of these symptoms?
Syphilis Symptoms?
Symptom
Duration
Anatomic
Onset Date
If Yes,
Facility/Provider Name: _______________________________________________
U
Code
(Days)
Site
1.
Facility Type:
U
2.
Exam Date: ________________
Diagnosis: ___________________________________________________
U
3.
Y
N
R
Referred for follow-up to STD-specialty care?
If Symptom Code = X or O, OR Anatomic Site = O, specify
Other than your current diagnosis, have you been previously
Have you ever been previously diagnosed with syphilis?
Y
N
R
diagnosed with any of the following infections in your lifetime?
If Yes, how many times? _________
Y
N
R
Chlamydia
If Yes, in past 12 mos.?
Y
N
R
Date of most recent diagnosis: ________________
Y
N
R
Gonorrhea
If Yes, in past 12 mos.?
Y
N
R
Y
N
R
Herpes
If Yes, in past 12 mos.?
Y
N
R
Stage at diagnosis:
R
HPV / Genital Warts
If Yes, in past 12 mos.?
R
Y
N
Y
N
Treated with: _______________________________________________
Y
N
R
Trichomoniasis
If Yes, in past 12 mos.?
Y
N
R
Date Treated: ________________
Hepatitis A
If Yes, in past 12 mos.?
Y
N
R
Y
N
R
Y
N
R
Hepatitis B
If Yes, in past 12 mos.?
Y
N
R
Name of Treating Facility/Provider: __________________________________
Hepatitis C
If Yes, in past 12 mos.?
Y
N
R
Y
N
R
Titer at diagnosis: _______
Y
N
R
Other: ___________
If Yes, in past 12 mos.?
Y
N
R
Unable to confirm
most recent diagnosis
Jurisdiction where diagnosed: ________
Have you ever been vaccinated for:
Hepatitis A
Hepatitis B
Y
N
U
R
Y
N
U
R
Interview/Field Record ID: _______________________
(2 shots)
(3 shots)
Substance Use:
Risk Factors/Social History:
In the 12 months prior to your syphilis diagnosis, did you use ...
In the 12 months prior to your syphilis diagnosis, have you ...
Y
N
R
Given money/drugs for sex?
Y
N
R
Methamphetamine
Y
Other: _________________
Y
N
R
Received money/drugs for sex?
Y
N
R
Y
Heroin
Other: _________________
Y
N
R
Had sex while intoxicated and/or high on drugs?
Y
N
R
Cocaine
Y
N
R
Had anonymous sex partners?
Y
N
R
Crack
Y
N
R
Been in a jail/juvenile detention facility?
Y
N
R
Ecstasy
Y
N
R
Been in a prison/long-term correctional facility?
Y
N
R
Marijuana
Y
N
R
Had a gang association?
If Yes, Name of Gang: ________________
Y
N
R
Erectile dysfunction drugs
Y
N
R
Nitrates/Poppers
Y
N
R
FEMALES ONLY: Had sex with person known to you to be MSM?
Were any of the above drugs injected?
If Yes, did you share needles?
Y
N
R
MALES ONLY: Had any pregnant partners?
Y
N
R
Y
N
R
Y
N
R
Prior to this syphilis diagnosis, did you know your HIV status?
If Yes, status:
Refused
Positive
Date of Diagnosis (mm/yy): _______________
Negative
Date of Last Test (mm/yy): _______________
Y
N
R
Did you have a current HIV test?
If Yes, date of current test (mm/yy): __________
Test result:
Positive
Negative
Didn’t return to get result
Inconclusive/discordant/invalid
Declined to disclose
Other: _____________________
Are you receiving HIV/EIP services?
Declined referral
Unknown
Y
N
Already in care
No, linked to care
If already in care or linked to care, confirmed with provider?
Facility/Provider Name: _______________________________________________
Page 3 of 9
CDPH 9063 (06/10) - CA Syphilis IR (11/3/2009)
State of California—Health and Human Services Agency
California Department of Public Health
Interview Record ID
PATIENT INTERVIEW
GENDER OF SEX PARTNERS IN PAST 12 MONTHS? (check all that apply)
Male
Female
MTF Transgender (TG)
FTM Transgender (TG)
Refused
PAST 12 MONTHS
PARTNERS OUTSIDE
INTERVIEW PERIOD PARTNERS
PARTNERS
THE INTERVIEW PERIOD
IX Period
Syphilis Only*
Syphilis & HIV
HIV Only
Clusters
# months: _______
Disclosure Type
Disclosure Type
Disclosure Type
# Males
________
Initiated
Total Partners
Hlth Dept
Dual
Self
Hlth Dept
Dual
Self
Hlth Dept
Dual
Self
# Females
________
# Males
________
________
________
________
________
________
________
________
________
________
________
# TG
________
# Females
________
________
________
________
________
________
________
________
________
________
________
# TG
________
________
________
________
________
________
________
________
________
________
________
# Anonymous
________
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
*
If OP HIV+, partners not notified of HIV exposure because:
Patient
Partners know they are HIV+: # _______
Patient will/did self-disclose: # _______
declined: # _______
VENUES
SEX PARTNER(S) RISKS
In the past 12 months, where have you met/had sex with new/anonymous partners?
For the following questions, “recent” refers to sex partners that
you had in the 12 months prior to your syphilis diagnosis
Meet Partners?
Sex Onsite?
Name(s) of Venues
Of recent sex partners, what was their HIV status?
(check all that apply)
Y
N
R
Y
N
R
R
Bars/Clubs:
__________________________________________
Positive
Negative
Unsure
Refused
_____________________________________________________
Y
N
R
Y
N
R
R
Have any recent sex partners been in jail, juvenile
Bathhouses/Sex Clubs:
________________________________
Y
N
U
R
detention, or prison/long-term corrections in the
_____________________________________________________
12 months prior to your syphilis diagnosis?
Y
N
R
N/A
R
Internet/Chatroom:
____________________________________
Did any recent sex partners use IDU drugs in the
Y
N
U
R
_____________________________________________________
12 months prior to your syphilis diagnosis?
R
Handles/ID:
__________________________________________
Did any recent sex partners use meth/speed in the
Y
N
U
R
Y
N
R
Y
N
R
R
Adult Bookstore/Cinemas:
______________________________
12 months prior to your syphilis diagnosis?
Y
N
R
Y
N
R
R
Circuit Party:
_________________________________________
Do you think it is likely that any of your recent sex partners were also
having sex with someone else while in a sexual relationship with you?
Y
N
R
Y
N
R
R
Gyms/Health Clubs:
___________________________________
Yes
Very likely
Somewhat likely
Not very likely
No
Y
N
R
Y
N
R
R
Jail/Prison:
__________________________________________
Y
N
R
Y
N
R
R
Motels/Hotels:
________________________________________
N/A
Y
N
R
R
Phone/Chatline:
______________________________________
Y
N
R
Y
N
R
R
Private Party:
________________________________________
Y
N
R
Y
N
R
R
Parks/Beach/Rest Area:
________________________________
SEXUAL PRACTICES IN PAST 12 MONTHS
Y
N
R
Y
N
R
R
Resorts:
____________________________________________
Sexual Activity
Frequency of Condom Use
Y
N
R
Y
N
R
R
Always
Sometimes
Never
Refused
School:
_____________________________________________
Y
N
R
Oral Insertive
Y
N
R
Y
N
R
R
Streets:
_____________________________________________
Y
N
R
Oral Receptive
Y
N
R
Y
N
R
R
Work:
______________________________________________
Y
N
R
Anal Insertive
Y
N
R
N/A
Social Network (e.g., friends)
Y
N
R
Anal Receptive
Y
N
R
Y
N
R
R
Other #1:
___________________________________________
Y
N
R
Vaginal
Y
N
R
Y
N
R
R
Other #2:
___________________________________________
Exposure Locations (Jurisdictions):
Refused/No Interview
Source Identified?
Yes
Probable
Possible
No
In-County
If Yes, Jurisdiction: ________
If Yes/Probable/Possible, residence jurisdiction(s): _______ _______ _______
In-State
If Yes, Jurisdiction: ________ ________ ________
In-Country
If Yes, Jurisdiction: ________ ________ ________
Imported Case?
Case Jurisdiction #: _______
N
C
S
J
D
U
Out-of-Country
If Yes, Jurisdiction: ________ ________ ________
Travel during the Interview Period?
Y
N
R
Travel Dates
Local Sex Partners?
Y
N
R
If Yes, where?
1. _____________________________________________________________
to
(include city & state)
Y
N
R
2. _____________________________________________________________
to
Other Interview Period Addresses (include city & state)
Dates
Living With / Relationship
to
to
Page 4 of 9
CDPH 9063 (06/10) - CA Syphilis IR (11/3/2009)
State of California—Health and Human Services Agency
California Department of Public Health
Interview Record ID
PARTNER/CLUSTER INFORMATION
AKA/
Last Name
First Name
Jurisdiction
Chat ID
1
First
Last
Y
N
U
Y
N
U
M
F
MTF
FTM
U
P/CL
Freq.
Sex
Pregnant
Spouse
Exposure
Exposure
Referral FR#
Dispo
Dx
Syphilis
Disease
Interview
1
Source/Spread
1
Date
Ix DIS #
Dispo Date
DIS #
If cluster, describe:
2
Ix Type
Dispo
Dx
Disease
3
Initiated
2
Date
Dispo Date
DIS #
AKA/
Last Name
First Name
Jurisdiction
Chat ID
2
First
Last
Y
N
U
Y
N
U
M
F
MTF
FTM
U
P/CL
Freq.
Sex
Pregnant
Spouse
Exposure
Exposure
Referral FR#
Dispo
Dx
Syphilis
Disease
Interview
1
Source/Spread
1
Date
Ix DIS #
Dispo Date
DIS #
If cluster, describe:
2
Ix Type
Dispo
Dx
Disease
Initiated
3
2
Date
Dispo Date
DIS #
AKA/
Last Name
First Name
Jurisdiction
Chat ID
3
First
Last
Y
N
U
Y
N
U
M
F
MTF
FTM
U
P/CL
Freq.
Sex
Pregnant
Spouse
Exposure
Exposure
Referral FR#
Dispo
Dx
Syphilis
Disease
Interview
1
Source/Spread
1
Date
Ix DIS #
Dispo Date
DIS #
If cluster, describe:
2
Ix Type
Dispo
Dx
Disease
3
Initiated
2
Date
Dispo Date
DIS #
AKA/
Last Name
First Name
Jurisdiction
Chat ID
4
First
Last
Y
N
U
Y
N
U
M
F
MTF
FTM
U
P/CL
Freq.
Sex
Pregnant
Spouse
Exposure
Exposure
Referral FR#
Dispo
Dx
Syphilis
Disease
Interview
1
Source/Spread
1
Date
Ix DIS #
Dispo Date
DIS #
If cluster, describe:
2
Ix Type
Dispo
Dx
Disease
3
Initiated
2
Date
Dispo Date
DIS #
AKA/
Last Name
First Name
Jurisdiction
Chat ID
5
First
Last
Y
N
U
Y
N
U
M
F
MTF
FTM
U
P/CL
Freq.
Sex
Pregnant
Spouse
Exposure
Exposure
Referral FR#
Dispo
Dx
Syphilis
Disease
Interview
1
Source/Spread
1
Date
Ix DIS #
Dispo Date
DIS #
If cluster, describe:
2
Ix Type
Dispo
Dx
Disease
Initiated
3
2
Date
Dispo Date
DIS #
AKA/
Last Name
First Name
Jurisdiction
6
Chat ID
First
Last
Y
N
U
Y
N
U
M
F
MTF
FTM
U
P/CL
Freq.
Sex
Pregnant
Spouse
Exposure
Exposure
Referral FR#
Dispo
Dx
Syphilis
Disease
Interview
1
Source/Spread
1
Date
Ix DIS #
Dispo Date
DIS #
If cluster, describe:
2
Ix Type
Dispo
Dx
Disease
3
Initiated
2
Date
Dispo Date
DIS #
Page 5 of 9
CDPH 9063 (06/10) - CA Syphilis IR (11/3/2009)