Form CDPH9078 "Request for Infectious Diseases Branch Surveillance Data" - California

What Is Form CDPH9078?

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 October 1, 2012;
  • 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 CDPH9078 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 CDPH9078 "Request for Infectious Diseases Branch Surveillance Data" - California

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State of California-Health and Human Services Agency
California Department of Public Health
REQUEST FOR INFECTIOUS DISEASES BRANCH SURVEILLANCE DATA
Return completed form (pages 1 & 2) to:
Please fill and print out requester information below.
Requester name:
Requester title:
California Department of Public Health
Center for Infectious Diseases
Organization:
Division of Communicable Disease Control
Infectious Diseases Branch
Mailing Address:
Surveillance and Statistics Section
P.O. Box 997377, MS 7306
Telephone number (include area code):
E-mail address:
Sacramento, CA 95899-7377
(
)
FAX number (include area code):
Date of request:
Desired completion date:
Email: IDB-SSS@CDPH.CA.GOV
(
)
Phone: (916) 552-9720
Please allow minimum of ten working days for completion of data request.
FAX:
(916) 552-9725
- Please refer to pages 2, 3 & 4 for instructions on how to complete your data request.
- For Public Records Act Requests please call the CDPH Press Office at: (916) 440-7259
Detailed Description of Data / Assistance Requested
1. Disease name(s):
4. Georgraphic area(s) requested:
Statewide
Jurisdictions:
5. Purpose of data request (check all that apply):
Advocacy
Program planning
Grant application
Report/journal article
2. Time period requested (month and/or year):
Internal use only
Research
Presentation
From __________________ To __________________
Other purpose (specify):
Cumulative for specific periods
By year
By other grouping, (please specify below):
6. Delivery method:
3. Demographic categories* (check all that apply):
Race/Ethnicity
Gender
Email
FAX
Mail
Age groups
Other (specify below):
7. Special Instructions:
Initials of the requester here:
Page 1 of 4
CDPH 9078 Rev. 10/12
Signature required on page 2.
State of California-Health and Human Services Agency
California Department of Public Health
REQUEST FOR INFECTIOUS DISEASES BRANCH SURVEILLANCE DATA
Return completed form (pages 1 & 2) to:
Please fill and print out requester information below.
Requester name:
Requester title:
California Department of Public Health
Center for Infectious Diseases
Organization:
Division of Communicable Disease Control
Infectious Diseases Branch
Mailing Address:
Surveillance and Statistics Section
P.O. Box 997377, MS 7306
Telephone number (include area code):
E-mail address:
Sacramento, CA 95899-7377
(
)
FAX number (include area code):
Date of request:
Desired completion date:
Email: IDB-SSS@CDPH.CA.GOV
(
)
Phone: (916) 552-9720
Please allow minimum of ten working days for completion of data request.
FAX:
(916) 552-9725
- Please refer to pages 2, 3 & 4 for instructions on how to complete your data request.
- For Public Records Act Requests please call the CDPH Press Office at: (916) 440-7259
Detailed Description of Data / Assistance Requested
1. Disease name(s):
4. Georgraphic area(s) requested:
Statewide
Jurisdictions:
5. Purpose of data request (check all that apply):
Advocacy
Program planning
Grant application
Report/journal article
2. Time period requested (month and/or year):
Internal use only
Research
Presentation
From __________________ To __________________
Other purpose (specify):
Cumulative for specific periods
By year
By other grouping, (please specify below):
6. Delivery method:
3. Demographic categories* (check all that apply):
Race/Ethnicity
Gender
Email
FAX
Mail
Age groups
Other (specify below):
7. Special Instructions:
Initials of the requester here:
Page 1 of 4
CDPH 9078 Rev. 10/12
Signature required on page 2.
State of California Health and Human Services Agency
California Department of Public Health
By submitting this data request I agree to the following provisions:
1. Protecting the confidentiality of surveillance information is our foremost concern. The release of surveillance data containing individually
identifying information is strictly prohibited. The terms and conditions for the release of data must be consistent with applicable laws.
2. We reserve the right to suppress data to maintain case confidentiality. Data tables will not contain potentially identifying information, small
cell values, or information on small population subgroups.
3. All publications using the data provided must acknowledge this program. The following is a suggested citation: California Department of
Public Health, Infectious Diseases Branch, Surveillance & Statistics Section, provisional infectious diseases data provided per Data Request,
<date>.
4. The dissemination of any interpretations or findings based upon the data provided must be accompanied by the following disclaimer: The
authorized release of infectious diseases data by the California Department of Public Health, Infectious Diseases Branch, Surveillance &
Statistics Section should not be construed as an endorsement of any analyses, interpretations, or conclusions reached by the author(s).
5. The data provided will be used only for the purposes stated in the data request form.
6. The data are provisional. Local Health Jurisdictions can modify or delete past case reports at any time, even months or years after they
are initially reported due to the dynamic nature of the reporting surveillance system.
7. Data should not be released to a third party who is not listed on the request form. The third party request should be referred directly to
California Department of Public Health, Infectious Diseases Branch, Surveillance & Statistics Section.
8. Research proposal involving human subjects may require approval of the California Health and Human Services Agency, Committee for
the Protection of Human Subjects, 400 R Street, Suite 359, Sacramento, CA 95811.6213, telephone: (916) 326-3660, websites:
cphs-mail@oshpd.ca.gov, or www.oshpd.ca.gov/boards/cphs.
9. Requesters agree not to use de-identified data to determine the identity of individual persons. Attempt to do so from public data is a
violation of the federal Privacy Act, 5U.S.C. and the HIPAA Rule.
10. Computer or paper files must be protected under lock and key and/or by encryption.
Signature
Type or print name of the requester
Date:
Note: If you email this form to expedite the process, you are still required to print out, initial, sign, and fax or mail the first two
pages accordingly.
Required By Civil Code Section for Use in
Request for Infectious Diseases Branch Surveillance Data Form
PRIVACY STATEMENT (CA CIVIL CODE SECTION 1798.17)
THE INFORMATION COLLECTED ON THIS FORM IS USED TO PROCESS YOUR REQUEST FOR INFECTIOUS DISEASES BRANCH SURVEILLANCE DATA.THIS INFORMATION WILL
BE KEPT CONFIDENTIAL AND ON FILE AT THE CALIFORNIA DEPARTMENT OF PUBLIC HEALTH, INFECTIOUS DISEASES BRANCH. ALL INFORMATION REQUESTED ON THE FORM
IS REQUIRED IN ORDER TO PROCESS YOUR REQUEST, AND NOT SUPPLYING THE INFORMATION MAY CAUSE A DELAY IN THE PROCESSING OF YOUR REQUEST, ORDENIAL
OF YOUR REQUEST. ANY INFORMATION PROVIDED MAYBE DISCLOSED TO THE CALIFORNIA STATE AUDITOR, THE CALIFORNIA OFFICE OF HEALTH INFORMATION INTEGRITY,
THE CALIFORNIA OFFICE OF INFORMATION SECURITY AND PRIVACY PROTECTION, OR TO OTHER STATE AND FEDERAL AGENCIES AS REQUIRED BY LAW.
YOU HAVE THE RIGHT TO REVIEW THE RECORDS WE KEEP ABOUT YOU DURING NORMAL BUSINESS HOURS. THE CALIFORNIA DEPARTMENT OF PUBLIC HEALTH PRIVACY
OFFICE WILL, UPON REQUEST, INFORM YOU REGARDING THE LOCATION OF YOUR RECORDS AND THE CATEGORIES OF ANY PERSONS WHO USE THE INFORMATION IN
THOSE RECORDS. FOR MORE INFORMATION, CONTACT THE CALIFORNIA DEPARTMENT OF PUBLIC HEALTH, PRIVACY OFFICE, USING THE FOLLOWING CONTACT
INFORMATION: CALIFORNIA DEPARTMENT OF PUBLIC HEALTH, OFFICE OF LEGAL SERVICES, PRIVACY OFFICE, MS 0506, P.O. BOX 997377, SACRAMENTO, CALIFORNIA
95899-7377 OR PHONE 1-877-421-9634 OR BY E-MAIL AT: Privacy@cdph.ca.gov
CDPH 9078 Rev. 10/12
Page 2 of 4
State of California-Health and Human Services Agency
California Department of Public Health
Instructions for filling out Data Request Form
Item 1: Disease Names
a) Please refer to accompanying disease list (page 4) for detailed information on what disease categories are available for
request through the Surveillance and Statistics Section (SSS), Infectious Diseases Branch.
b) Write disease names as shown on disease list.
c) List is based on diseases reportable to the State of California (Title 17 CCR §2500).
Item 2: Time Period:
a) Specify both lower and upper bound for time period requested (month/year).
b) The time period for data requests is based on the period during which cases were reported. The date of disease onset may
not be available.
c) Please note: Disease reporting requirements change:
- Diseases that were reportable in the past may not be reportable now,
- Diseases that are currently reportable may have not been previously reportable for a period of time.
Item 3: Demographic Categories:
a) Demographic information for outbreaks is not available.
Item 4: Geographic Areas:
a) There are 61 local health jurisdictions: 58 counties and the cities of Berkeley, Long Beach, and Pasadena.
b) For information on a specific local health jurisdiction, please contact local health jurisdiction directly.
http://www.cdph.ca.gov/HealthInfo/Documents/LHD_CD_Contact_Info.pdf
Item 5: Delivery Method:
a) Results will be emailed to specified address if no method is selected.
Item 6: Purpose of Data Request:
a) Check all that apply.
Item 7: Special Instructions:
a) Use this area to add any special instructions that were not covered elsewhere. SSS will do their best to address your
requests.
CDPH 9078 Rev. 10/12
Page 3 of 4
State of California Health and Human Services Agency
California Department of Public Health
Please visit the following website for available data and reports before completing the data request form.
1994 - 2012 data are available under "Data and Statistics" on Section's website at:
http://www.cdph.ca.gov/programs/sss/Pages/default.aspx
Diseases
Amebiasis
Lyme Disease
Anthrax
Malaria
Babesiosis
Paralytic Shellfish Poisoning
Botulism (Foodborne, Wound)
Plague, Human or Animal
Brucellosis
Psittacosis
Campylobacteriosis
Q Fever
Cholera
Rabies, Animal
Ciguatera Fish Poisoning
Relapsing Fever
Coccidioidomycosis
Rocky Mountain Spotted Fever
Creutzfeldt-Jakob Disease (CJD) and other Transmissible
Salmonellosis (Other than Typhoid Fever)
Spongiform Encephalopathies (TSE) (reportable since 1996)
Scombroid Fish Poisoning
Cryptosporidiosis
Shiga toxin (detected in feces)
Cyclosporiasis
Shigellosis
Cysticercosis or Taeniasis
Staphylococcus aureus infection *
Dengue
Streptococcal Infections (Outbreaks of Any Type & Individual
cases in Food Handlers and Dairy Workers only)
Domoic Acid Poisoning (Amnesic Shellfish Poisoning)
Ehrlichiosis
Trichinosis
Escherichia coli : shiga toxin producing (STEC) including
Tularemia
E. coli O157
Typhoid Fever, Cases and Carriers
Giardiasis
Typhus Fever
Hantavirus Infections
Vibrio Infections
Hemolytic Uremic Syndrome
West Nile (animal or vector issues)
Hepatitis E, acute infection
Yersiniosis
Legionellosis
Outbreak Only
Leprosy (Hansen's Disease)
Leptospirosis
Foodborne Disease
Listeriosis
Waterborne Disease
* Only cases resulting in death or admission to an intensive care unit of a person who has not been hospitalized or had surgery, dialysis, or residency in a
long term care facility in the past year, and did not have an indwelling catheter or percutaneous medical device at the time of culture are reported.
For other diseases, please check the following programs (business hours: M - F, 8 am - 5 pm) and websites:
Communicable Disease Emergency Response Branch [Main line: (510) 231-6861]
http://www.cdph.ca.gov/programs/cder/Pages/default.aspx
Immunizatin Branch [Main line: (510) 620-3737]
http://www.cdph.ca.gov/programs/immunize/Pages/default.aspx
Infant Botulism Treatment and Prevention [Main line: (510) 231-7600]
http://www.cdph.ca.gov/programs/ibtpp/Pages/default.aspx
Sexually Transmitted Diseases Branch [Main line: (510) 620-3400]
http://www.cdph.ca.gov/programs/std/Pages/default.aspx
Tuberculosis Control Branch [Main line: (510) 620-3000]
http://www.cdph.ca.gov/programs/tb/Pages/default.aspx
Viral & Rickettsial Diseases Laboratory Branch [Main line: (510) 307-8575]
http://www.cdph.ca.gov/programs/vrdl/Pages/default.aspx
CDPH 9078 Rev. 10/12 (Rev. update 11/13)
Page of 4