Form CDPH8584 "' yellow Fever Case Report" - California

What Is Form CDPH8584?

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, 2011;
  • 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 CDPH8584 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 CDPH8584 "' yellow 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
YELLOW FEVER
CASE REPORT
PATIENT INFORMATION
Primary Language
Last Name
First Name
Middle Name
Suffix
English
Spanish
Social Security Number (9 digits)
DOB (mm/dd/yyyy)
Age
Years
Other:_____________________
Months
Days
Ethnicity (check one)
Address Number & Street - Residence
Apartment/Unit Number
Hispanic/Latino
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
Home Telephone
Cellular Phone/Pager
Work/School Telephone
Cambodian
Korean
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
Other: _______________________________
Male
Female
Other:_____________________
Pregnant?
If Yes, Est. Delivery Date (mm/dd/yyyy)
White
Yes
No
Unk
Other:____________________
Medical Record Number
Patient’s Parent/Guardian Name
Unk
*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
CDPH 8584 (revised 11/11)
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 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
YELLOW FEVER
CASE REPORT
PATIENT INFORMATION
Primary Language
Last Name
First Name
Middle Name
Suffix
English
Spanish
Social Security Number (9 digits)
DOB (mm/dd/yyyy)
Age
Years
Other:_____________________
Months
Days
Ethnicity (check one)
Address Number & Street - Residence
Apartment/Unit Number
Hispanic/Latino
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
Home Telephone
Cellular Phone/Pager
Work/School Telephone
Cambodian
Korean
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
Other: _______________________________
Male
Female
Other:_____________________
Pregnant?
If Yes, Est. Delivery Date (mm/dd/yyyy)
White
Yes
No
Unk
Other:____________________
Medical Record Number
Patient’s Parent/Guardian Name
Unk
*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
CDPH 8584 (revised 11/11)
Page 1 of 6
California Department of Public Health
YELLOW FEVER CASE REPORT
First three letters of
patient’s last name:
SIGNS AND SYMPTOMS
Symptomatic?
Onset Date (mm/dd/yyyy)
Date First Sought Medical Care (mm/dd/yyyy)
Yes No Unk
Signs and Symptoms
Yes
No
Unk
Signs and Symptoms
Yes
No
Unk
Fever, If Yes, highest temperature (specify °F/°C)
Abdominal pain
Chills
Hematemesis
Severe headache
Epistaxis
Muscle aches
Gum bleeding
Nausea
Purpura hemorrhages
Fatigue
Deepening jaundice
Weakness
Proteinuria
Back pain
Other signs / symptoms (specify)
VACCINATION / MEDICAL HISTORY
Vaccinated for yellow fever?
If Yes, date of first vaccine (mm/dd/yyyy)
Date of most recent booster (mm/dd/yyyy)
Yes No Unk
CLINICAL COMPLICATIONS
Clinical complications for this attack?
If Yes, specify
Yes No Unk
Other (specify)
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
OUTCOME
Outcome?
If Survived,
Date of Death (mm/dd/yyyy)
Survived as of ________________________________(mm/dd/yyyy)
Survived Died Unk
CDPH 8584 (revised 11/11)
Page 2 of 6
California Department of Public Health
YELLOW FEVER CASE REPORT
First three letters of
patient’s last name:
ADDITIONAL COMMENTS
LABORATORY INFORMATION
LABORATORY RESULTS SUMMARY
Specimen Type 1
Collection Date (mm/dd/yyyy)
Type of Test
Blood
Smear Serology (specify):_____________ Other:____________
Other (specify):_________________
Result
Interpretation
Positive
Negative
Equivocal
Laboratory Name
Telephone Number
Specimen Type 2
Type of Test
Collection Date (mm/dd/yyyy)
Serology (specify):____________ Other:_____________
Blood
Smear
Other (specify):_________________
Result
Interpretation
Positive
Negative
Equivocal
Laboratory Name
Telephone Number
OTHER LABORATORY TESTS
Test for other flaviviruses?
If Yes, specify flavivirus(es)
Outcome of Tests
Yes No Unk
EPIDEMIOLOGIC INFORMATION
TRAVEL HISTORY (INCUBATION PERIOD IS 3 MONTHS PRIOR TO ILLNESS ONSET)
Did patient travel or live outside of the U.S. during the incubation period?
If Yes, specify the following and all locations and dates below.
Yes No Unk
Principal reason for travel from / to U.S. for most recent trip
Peace Corps
Airline / ship crew
Visiting friends / relatives
Refugee / immigrant
Tourism
Student / teacher
Missionary or dependent
Other (specify):___________________________
Military
Business
TRAVEL HISTORY - DETAILS
Location (city, county, state, country)
Date Travel Started (mm/dd/yyyy)
Date Travel Ended (mm/dd/yyyy)
CDPH 8584 (revised 11/11)
Page 3 of 6
California Department of Public Health
YELLOW FEVER CASE REPORT
First three letters of
patient’s last name:
CONTACTS / OTHER ILL PERSONS
Any contacts with similar illness?
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 of First Report (mm/dd/yyyy)
First Reported By
Officer Releasing Antitoxin - Last Name, First Name
Clinician Laboratory Other (specify):______________________
EPIDEMIOLOGICAL LINKAGE
Epi-linked to known case?
Contact Name / Case Number
Yes
No
Unk
DISEASE CASE CLASSIFICATION
Case Classification (see case definition on page 5)
Confirmed
Probable
OUTBREAK
Part of known outbreak?
If Yes, extent of outbreak:
One CA jurisdiction
Multiple CA jurisdictions
Other (specify):____________
Yes No Unk
Multistate
International
Unk
Vehicle of Outbreak
Pattern 1 ID number
Pattern 2 ID number
CDPH 8584 (revised 11/11)
Page 4 of 6
California Department of Public Health
YELLOW FEVER CASE REPORT
First three letters of
patient’s last name:
STATE USE ONLY
State Case Classification
Confirmed Probable Not a case Need additional information
CASE DEFINITION
YELLOW FEVER (2010)
CLINICAL DESCRIPTION
A mosquito-borne viral illness characterized by acute onset and constitutional symptoms followed by a brief remission and a recurrence of fever, hepatitis,
albuminuria, and symptoms and, in some instances, renal failure, shock, and generalized hemorrhages.
LABORATORY CRITERIA FOR DIAGNOSIS
Fourfold or greater rise in yellow fever antibody titer in a patient who has no history of recent yellow fever vaccination and cross-reactions to other flaviviruses
have been excluded or demonstration of yellow fever virus, antigen, or genome in tissue, blood, or other body fluid.
CASE CLASSIFICATION
Probable:
a clinically compatible case with supportive serology (stable elevated antibody titer to yellow fever virus [e.g., greater than or equal to 32 by
complement fixation, greater than or equal to 256 by immunofluorescence assay, greater than or equal to 320 by hemagglutination inhibition,
greater than or equal to 160 by neutralization, or a positive serologic result by immunoglobulin M-capture enzyme immunoassay].
Cross-reactive serologic reactions to other flaviviruses must be excluded, and the patient must not have a history of yellow fever vaccination.)
Confirmed: a clinically compatible case that is laboratory confirmed.
CDPH 8584 (revised 11/11)
Page 5 of 6