Form CDPH8527 "Viral Hemorrhagic Fever Case Report" - California

What Is Form CDPH8527?

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 August 1, 2014;
  • 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 CDPH8527 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 CDPH8527 "Viral Hemorrhagic Fever 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
VIRAL HEMORRHAGIC FEVER
CASE REPORT
Check one:
  Ebola
  Crimean-Congo hemorrhagic fever
  Lassa
  New World arenavirus (Guanarito, Junin, Machupo, Sabia viruses)
  Lujo
  Other: _______________________________________________
  Marburg
Jurisdictions participating in CalREDIE should create a CalREDIE incident and upload the completed form to the Electronic Filing
Cabinet. Jurisdictions not participating in CalREDIE should fax the completed form to (916) 552-8973. (Note: Dengue, Yellow Fever,
and Hantavirus each have their own case report forms.)
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)
 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 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
 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
 Pacific Islander (check all that apply)
 Native Hawaiian
 Samoan
Gender
 Guamanian
 Male
 Female
 Other: _______________________________
 Other:_____________________
 White
Medical Record Number
Patient’s Parent / Guardian Name
 Other:____________________
 Unk
Occupation Setting (see list on page 7)
Other (Describe / Specify)
*Comment: self-identity or self-reporting
Occupation (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
more than one racial designation.
CLINICAL INFORMATION
Physician Name - Last Name
First Name
Telephone Number
CDPH 8527 (8/14)
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
VIRAL HEMORRHAGIC FEVER
CASE REPORT
Check one:
  Ebola
  Crimean-Congo hemorrhagic fever
  Lassa
  New World arenavirus (Guanarito, Junin, Machupo, Sabia viruses)
  Lujo
  Other: _______________________________________________
  Marburg
Jurisdictions participating in CalREDIE should create a CalREDIE incident and upload the completed form to the Electronic Filing
Cabinet. Jurisdictions not participating in CalREDIE should fax the completed form to (916) 552-8973. (Note: Dengue, Yellow Fever,
and Hantavirus each have their own case report forms.)
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)
 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 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
 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
 Pacific Islander (check all that apply)
 Native Hawaiian
 Samoan
Gender
 Guamanian
 Male
 Female
 Other: _______________________________
 Other:_____________________
 White
Medical Record Number
Patient’s Parent / Guardian Name
 Other:____________________
 Unk
Occupation Setting (see list on page 7)
Other (Describe / Specify)
*Comment: self-identity or self-reporting
Occupation (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
more than one racial designation.
CLINICAL INFORMATION
Physician Name - Last Name
First Name
Telephone Number
CDPH 8527 (8/14)
Page 1 of 7
California Department of Public Health
VIRAL HEMORRHAGIC FEVER CASE REPORT
First three letters of
patient’s last name:
SIGNS AND SYMPTOMS
Symptom Onset Date (mm/dd/yyyy)
Date First Sought Medical Care (mm/dd/yyyy)
Signs and Symptoms
Yes
No
Unk
Signs and Symptoms
Yes
No
Unk
Fever
Abdominal pain
If Yes, highest temperature (specify °F/°C):__________
Bleeding not related to injury
Headache
If Yes, type of bleeding
Maculopapular rash
 Nose bleed
 Black or bloody stool
 Vomiting blood
 Hemorrhagic or purpuric rash
 Coughing up blood
 Other: _________________
Muscle pain (myalgia)
Joint pain
Pharyngitis (arenavirus only)
Vomiting
Retrosternal chest pain (arenavirus only)
Other signs / symptoms (specify)
Diarrhea
ER / HOSPITALIZATION
Did patient visit emergency room for illness?
Was patient hospitalized?
Was patient placed in isolation?
 Yes
 No
 Unk
 Yes
 No
 Unk
 Yes
 No
 Unk
If there were any ER or hospital stays related to this illness, specify details below.
ER / HOSPITALIZATION - DETAILS
ER / 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
ER / 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
OUTCOME
Outcome?
If Survived,
 Survived
Survived as of __________________________(mm/dd/yyyy)
 Died
If Died, Date of Death (mm/dd/yyyy)
Was death caused by this illness?
 Unk
 Yes
 No
 Unk
CDPH 8527 (8/14)
Page 2 of 7
California Department of Public Health
VIRAL HEMORRHAGIC FEVER CASE REPORT
First three letters of
patient’s last name:
LABORATORY INFORMATION
LABORATORY RESULTS SUMMARY (Please submit copies of all labs, including CBCs associated with this illness.)
Type of Virus Detected
Specimen Type (check all that apply)
 Ebola
 Crimean-Congo hemorrhagic fever
 Blood, date collected: ___/___/_____
 Lassa
 New World arenavirus (Guanarito, Junin, Machupo, Sabia viruses)
 Tissue, date collected: ___/___/_____
 Lujo
 Other:__________________________________
 Other:____________________, date collected: ___/___/_____
 Marburg
Laboratory Name
Telephone Number
Result
Test
Detected
Not Detected
Inconclusive
Unsatisfactory
Test Not Done
Polymerase chain reaction (PCR)
Antigen-capture enzyme-linked immunosorbent assay (ELISA)
IgM ELISA
IgG ELISA
Immunohistochemistry
Virus isolation
Other (specify): __________________________
ADDITIONAL LABORATORY RESULTS
DID THE PATIENT HAVE ANY OF THE FOLLOWING?
Result
Yes
No
Unk
If Yes, Specify as Noted
Lowest WBC
Leukopenia (WBC < 4,000 mm
)
3
Lowest lymphocytes count
Lymphocytopenia (lymphocytes < 1,000 mm
)
3
Lowest platelet count
Thrombocytopenia (platelets <150,000 mm
)
3
Proteinuria
Highest AST
Highest ALT
Elevated liver AST / ALT
Prolonged prothrombin time (PT)
Prolonged partial thromboplastin time (PTT or aPTT)
Other Pathogens Isolated
CDPH 8527 (8/14)
Page 3 of 7
California Department of Public Health
VIRAL HEMORRHAGIC FEVER CASE REPORT
First three letters of
patient’s last name:
EPIDEMIOLOGIC INFORMATION
INCUBATION PERIOD: 2 TO 21 DAYS PRIOR TO ONSET OF ILLNESS
TRAVEL HISTORY
Did patient travel outside of county of residence during the incubation period?
Did the patient travel outside the U.S. during the incubation period?
 Yes
 No
 Unk
 Yes
 No
 Unk
If Yes for either of these questions, specify all locations and dates below.
TRAVEL HISTORY - DETAILS
Location (city, county, state, country)
Date Travel Started (mm/dd/yyyy)
Date Travel Ended (mm/dd/yyyy)
EXPOSURE / RISK FACTORS
DID THE PATIENT EXPERIENCE ANY OF THE FOLLOWING EXPOSURES DURING THE INCUBATION PERIOD?
Exposure
Yes
No
Unk
If Yes, Provide Additional Details or Specify as Noted
Contact with a deceased person
Contact with a primate (e.g., monkey,
chimpanzee, etc.)
Contact with foreign arrival (e.g., visitor,
immigrant, adoptee, etc.)
Exposure Type
Date of Last Contact
Contact with blood or body fluids of a
(mm/dd/yyyy)
 Blood
 Respiratory secretions
confirmed acute case of VHF (within
 Semen
 Other (specify): ______________________
3 weeks of illness onset date)
Exposure Type
Date of Last Contact
Contact with body fluids of a confirmed
(mm/dd/yyyy)
 Blood
 Respiratory secretions
convalescent case of VHF (within
 Semen
 Other (specify): ______________________
10 weeks of illness onset date)
Occupation Type
Exposure Date(s)
(mm/dd/yyyy)
 Laboratory worker in a facility that handles VHF specimens
 Laboratory worker in a facility that handles bats, rodents or
Possible occupational exposure
primates from endemic areas
 Healthcare worker in a facility with VHF patients
 Other occupation: _________________________________
Transfusion Date(s) (mm/dd/yyyy)
Blood transfusion recipient 30 days prior
to onset
Transplant Date(s) (mm/dd/yyyy)
Organ transplant recipient 30 days prior
to onset
In what country did exposure likely occur?
Did the patient donate blood products, organs, or
Agency / Location
Type of Donation
Date(s) (mm/dd/yyyy)
If Yes,
tissue in the 30 days prior to symptom onset?
specify:
 Yes
 No
 Unk
CDPH 8527 (8/14)
Page 4 of 7
California Department of Public Health
VIRAL HEMORRHAGIC FEVER CASE REPORT
First three letters of
patient’s last name:
CONTACTS / OTHER ILL PERSONS
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)
NOTES / REMARKS
REPORTING AGENCY
Investigator Name
Local Health Jurisdiction
Telephone Number
Date (mm/dd/yyyy)
First Reported By
Health education provided?
Restriction / clearance needed?
 Clinician  Laboratory  Other (specify):______________________
 Yes
 No
 Unk
 Yes
 No
 Unk
EPIDEMIOLOGICAL LINKAGE
Epi-linked to known case?
Contact Name / Case Number
 Yes
 No
 Unk
DISEASE CASE CLASSIFICATION
Case Classification (see case definition on page 6)
 Confirmed
 Suspected
 Not a case
OUTBREAK
Part of known outbreak?
If Yes, extent of outbreak:
 Yes
 No
 Unk
 One CA jurisdiction
 Multiple CA jurisdictions
 Multistate
 International
 Unk
 Other (specify):____________
STATE USE ONLY
State Case Classification
 Confirmed
 Suspected
 Not a case
 Need additional information
CDPH 8527 (8/14)
Page 5 of 7