Form CDPH8554 "Other Outbreak or Other Reportable Disease or Disease of Unusual Occurrence" - California

What Is Form CDPH8554?

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 fillable version of Form CDPH8554 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 CDPH8554 "Other Outbreak or Other Reportable Disease or Disease of Unusual Occurrence" - California

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California Department of Public Health
State of California—Health and Human Services Agency
Surveillance and Statistics Section
P.O. Box 997377, MS 7306
Sacramento, CA 95899-7377
OTHER OUTBREAK
(Use CDC 52.12 for waterborne disease outbreaks; CDC 52.13 for foodborne disease outbreaks.)
OTHER REPORTABLE DISEASE
DISEASE OF UNUSUAL OCCURRENCE
OR
Confirmed
Not confirmed
Suspected
Kind of outbreak/illness
PERSONAL DATA—FOR SINGLE CASE ONLY
Patient name–last
first
middle initial
Date of birth
Age
Sex
Address–number, street
City
State
County
ZIP code
RACE (check one)
ETHNICITY (check one)
African-American/Black
White
Native American
Asian/Pacific Islander
Other ____________________
Hispanic/Latino
Non-Hispanic/Non-Latino
Asian Indian
Cambodian
Chinese
Filipino
Guamanian
Hawaiian
If Asian/Pacific Islander, please check one:
Japanese
Korean
Laotian
Samoan
Vietnamese
Other________________
LOCATION AND SCOPE OF OUTBREAK—FOR OUTBREAK ONLY
City
County
Name of community, camp, or institution
Population at risk
Number of persons investigated
Number of persons ill
Number of cases laboratory
Number hospitalized
Number of deaths
epidemiologically
confirmed
Date of Onset
Number of
Under 1 year
1–4 years
5–9 years
10–19 years
20–39 years
40–59 years
60 and over
persons ill by
First case:
Last case:
age group
REASON FOR INVESTIGATION
Was the California Department of Public Health notified?
Yes
No
HISTORY OF ILLNESS
Brief description of clinical course and the characteristics of the epidemic or case. Include date of onset and hospitalization for case.
Incubation period (range in hours or days)
Average duration of symptoms
Outcome of case
Recovered
Fatal
Date of death
_______________________
Minimum:
Maximum:
DIAGNOSTIC TESTS
SPECIMENS
TYPE
RESULTS
DATE
OF
Number of
Number
Type
Patients
COLLECTED
TEST
Positive
Etiology
NAME AND ADDRESS OF LABORATORY
RESULTS OF INVESTIGATION AND REMARKS
Summary of investigation, giving probable source with sustaining evidence; also name and address of suspected carrier or missed cases.
(WORK SHEET AVAILABLE ON REVERSE SIDE)
Page 1 of 2
CDPH 8554 (07/07) (This replaces 10/03 version.)
California Department of Public Health
State of California—Health and Human Services Agency
Surveillance and Statistics Section
P.O. Box 997377, MS 7306
Sacramento, CA 95899-7377
OTHER OUTBREAK
(Use CDC 52.12 for waterborne disease outbreaks; CDC 52.13 for foodborne disease outbreaks.)
OTHER REPORTABLE DISEASE
DISEASE OF UNUSUAL OCCURRENCE
OR
Confirmed
Not confirmed
Suspected
Kind of outbreak/illness
PERSONAL DATA—FOR SINGLE CASE ONLY
Patient name–last
first
middle initial
Date of birth
Age
Sex
Address–number, street
City
State
County
ZIP code
RACE (check one)
ETHNICITY (check one)
African-American/Black
White
Native American
Asian/Pacific Islander
Other ____________________
Hispanic/Latino
Non-Hispanic/Non-Latino
Asian Indian
Cambodian
Chinese
Filipino
Guamanian
Hawaiian
If Asian/Pacific Islander, please check one:
Japanese
Korean
Laotian
Samoan
Vietnamese
Other________________
LOCATION AND SCOPE OF OUTBREAK—FOR OUTBREAK ONLY
City
County
Name of community, camp, or institution
Population at risk
Number of persons investigated
Number of persons ill
Number of cases laboratory
Number hospitalized
Number of deaths
epidemiologically
confirmed
Date of Onset
Number of
Under 1 year
1–4 years
5–9 years
10–19 years
20–39 years
40–59 years
60 and over
persons ill by
First case:
Last case:
age group
REASON FOR INVESTIGATION
Was the California Department of Public Health notified?
Yes
No
HISTORY OF ILLNESS
Brief description of clinical course and the characteristics of the epidemic or case. Include date of onset and hospitalization for case.
Incubation period (range in hours or days)
Average duration of symptoms
Outcome of case
Recovered
Fatal
Date of death
_______________________
Minimum:
Maximum:
DIAGNOSTIC TESTS
SPECIMENS
TYPE
RESULTS
DATE
OF
Number of
Number
Type
Patients
COLLECTED
TEST
Positive
Etiology
NAME AND ADDRESS OF LABORATORY
RESULTS OF INVESTIGATION AND REMARKS
Summary of investigation, giving probable source with sustaining evidence; also name and address of suspected carrier or missed cases.
(WORK SHEET AVAILABLE ON REVERSE SIDE)
Page 1 of 2
CDPH 8554 (07/07) (This replaces 10/03 version.)
Other Outbreaks OR Unusual Disease Report—CDPH 8554—Page 2 of 2
Write in spaces below: signs, symptoms, and
laboratory findings observed in this outbreak.
PATIENT’S NAME AND ADDRESS
DATE
OF
DATE
EXPOSURE
OF
AGE
(IF KNOWN)
ONSET
INVESTIGATOR—Investigator’s name
Date
Telephone Number
(
)
Investigator’s agency name
Page 2 of 2
CDPH 8554 (07/07)
Page of 2