Form CDPH8345 "Measles (Rubeola) Case Report" - California

What Is Form CDPH8345?

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, 2008;
  • 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 CDPH8345 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 CDPH8345 "Measles (Rubeola) Case Report" - California

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Mail to:
California Department of Public Health
Immunization Branch
850 Marina Bay Parkway
nd
Building P, 2
Floor, MS 7313
Richmond, CA 94804-6403
Or Fax to: (510) 620-3949
MEASLES (RUBEOLA) CASE REPORT
PATIENT DEMOGRAPHICS
Patient name—last
first
middle initial
Date of birth
Age (enter age and check one)
Gender
/___/___
Male
Female
____
Days
Weeks
Months
Years
/
Address—number, street
City
State
ZIP code
County
Telephone number
Email:
(
)
(
)
Home
Work
ETHNICITY (check one)
RACE (check all that apply)
Hispanic/Latino
Black/African-American
Asian: Please specify:
Pacific Islander: Please specify:
Non-Hispanic/ Non-Latino
Native American/Alaskan Native
Asian Indian
Hmong
Thai
Native Hawaiian
Unknown
White
Cambodian
Japanese
Vietnamese
Guamanian
Unknown
Chinese
Korean
Other Asian:
Samoan
Other: _________________
Filipino
Laotian
_________________
Other Pacific Islander:
__________________
Country of birth
Country of residence
COMMON LHD TRACKING DATA
CMRID Number
IZB Case ID Number
WebCMR ID Number
Date reported to county
Date investigation started
Person/clinician reporting case
Reporter telephone
/
/_____
/
/_____
(
)
Case investigator completing form
Investigator telephone
Investigator’s jurisdiction
(
)
SIGNS AND SYMPTOMS
Rash
Rash onset date
Rash duration
Generalized rash
Origin on body
Direction of spread
/
/_____
Yes
No
Unknown
________
Yes
No
Unknown
days
Fever
Was temperature taken
Was temperature >101F (38.3C)
If temperature not taken, skin was
Fever onset date
/
/_____
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Hot
Warm
Normal
Unknown
Cough
Runny nose (coryza)
Conjunctivitis
Koplik’s spots
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Other symptoms
Describe other symptoms
Diagnosis date
/
/_____
Yes
No
Unknown
Does case meet clinical criteria for further investigation?
CASE MEETS CDC/CSTE CLINICAL CRITERIA? (FOR STATE USE ONLY)
Yes
No
Unknown
Yes
No
Unknown
COMPLICATIONS AND OTHER SYMPTOMS
Hospitalized
Days hospitalized
Pneumonia
Encephalitis
Death
If yes, date of death
_ /
_/____
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Other complications
If yes, describe other complications
Yes
No
Unknown
LABORATORY TESTS
Lab tests done for measles
CASE LAB CONFIRMED (FOR LHD USE)
CASE LAB CONFIRMED (FOR STATE USE ONLY)
LAB RESULT CODES
P = Positive
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
N = Negative – Antibody not detected
Serology performed
I = Indeterminate
E = Pending
Yes
No
Unknown
Specimen date
Result interpretation
X = Not Done
IgM
P
N
I
E
X
U
/
/______
U = Unknown
IgG (acute)
P
N
I
E
X
U
/
/______
IgG (convalescent)
P
N
I
E
X
U
/
/______
Specimen obtained for virus isolation
Specimen source
Specimen date
Virus isolated
Name of lab:
/
/_____
Yes
No
Unknown
Nasopharyngeal
Urine
Other
Unknown
Yes
No
Unknown
Specimen sent to CDC for genotyping
Date sent
Virus genotype
Yes
No
Unknown
/
/______
Other lab tests performed
Other lab test specimen date
Specify other lab tests
Other lab test results
/
/______
Yes
No
Unknown
Page 1 of 2
CDPH 8345 (8/08)
Mail to:
California Department of Public Health
Immunization Branch
850 Marina Bay Parkway
nd
Building P, 2
Floor, MS 7313
Richmond, CA 94804-6403
Or Fax to: (510) 620-3949
MEASLES (RUBEOLA) CASE REPORT
PATIENT DEMOGRAPHICS
Patient name—last
first
middle initial
Date of birth
Age (enter age and check one)
Gender
/___/___
Male
Female
____
Days
Weeks
Months
Years
/
Address—number, street
City
State
ZIP code
County
Telephone number
Email:
(
)
(
)
Home
Work
ETHNICITY (check one)
RACE (check all that apply)
Hispanic/Latino
Black/African-American
Asian: Please specify:
Pacific Islander: Please specify:
Non-Hispanic/ Non-Latino
Native American/Alaskan Native
Asian Indian
Hmong
Thai
Native Hawaiian
Unknown
White
Cambodian
Japanese
Vietnamese
Guamanian
Unknown
Chinese
Korean
Other Asian:
Samoan
Other: _________________
Filipino
Laotian
_________________
Other Pacific Islander:
__________________
Country of birth
Country of residence
COMMON LHD TRACKING DATA
CMRID Number
IZB Case ID Number
WebCMR ID Number
Date reported to county
Date investigation started
Person/clinician reporting case
Reporter telephone
/
/_____
/
/_____
(
)
Case investigator completing form
Investigator telephone
Investigator’s jurisdiction
(
)
SIGNS AND SYMPTOMS
Rash
Rash onset date
Rash duration
Generalized rash
Origin on body
Direction of spread
/
/_____
Yes
No
Unknown
________
Yes
No
Unknown
days
Fever
Was temperature taken
Was temperature >101F (38.3C)
If temperature not taken, skin was
Fever onset date
/
/_____
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Hot
Warm
Normal
Unknown
Cough
Runny nose (coryza)
Conjunctivitis
Koplik’s spots
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Other symptoms
Describe other symptoms
Diagnosis date
/
/_____
Yes
No
Unknown
Does case meet clinical criteria for further investigation?
CASE MEETS CDC/CSTE CLINICAL CRITERIA? (FOR STATE USE ONLY)
Yes
No
Unknown
Yes
No
Unknown
COMPLICATIONS AND OTHER SYMPTOMS
Hospitalized
Days hospitalized
Pneumonia
Encephalitis
Death
If yes, date of death
_ /
_/____
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Other complications
If yes, describe other complications
Yes
No
Unknown
LABORATORY TESTS
Lab tests done for measles
CASE LAB CONFIRMED (FOR LHD USE)
CASE LAB CONFIRMED (FOR STATE USE ONLY)
LAB RESULT CODES
P = Positive
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
N = Negative – Antibody not detected
Serology performed
I = Indeterminate
E = Pending
Yes
No
Unknown
Specimen date
Result interpretation
X = Not Done
IgM
P
N
I
E
X
U
/
/______
U = Unknown
IgG (acute)
P
N
I
E
X
U
/
/______
IgG (convalescent)
P
N
I
E
X
U
/
/______
Specimen obtained for virus isolation
Specimen source
Specimen date
Virus isolated
Name of lab:
/
/_____
Yes
No
Unknown
Nasopharyngeal
Urine
Other
Unknown
Yes
No
Unknown
Specimen sent to CDC for genotyping
Date sent
Virus genotype
Yes
No
Unknown
/
/______
Other lab tests performed
Other lab test specimen date
Specify other lab tests
Other lab test results
/
/______
Yes
No
Unknown
Page 1 of 2
CDPH 8345 (8/08)
Measles (Rubeola) Case Report—CDPH 8258
VACCINATION/MEDICAL HISTORY
Received one or more doses of measles containing vaccine (MCV)
Number of doses
Yes
No
Unknown
Dates of vaccination–Dose 1
Dose 2
Dose 3
/
/______
/
/______
/
/______
Reason not vaccinated (check all that apply)
1
Personal Beliefs Exemption (PBE)
4
Lab confirmation of previous disease
7
Delay in starting series or between doses
2
Permanent Medical Exemption (PME)
5
MD diagnosis of previous disease
8
Other
3
Temporary Medical Exemption
6
Under age for vaccination
9
Unknown
Prior MD diagnosed measles (see reason 5)
Pregnant
Immunocompromised
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
EPIDEMIOLOGICAL EXPOSURE HISTORY
Spread Setting (check all that apply)
1
Day care
4
Hospital Ward
7
Home
10
College
13
Church
2
School
5
Hospital ER
8
Work
11
Military
14
International travel
3
Doctor’s office
6
Outpatient hospital clinic
9
Unknown
12
Correctional facility
15
Other
Recent travel or arrival from other country or state within 18 days of rash onset?
Yes
No
Unknown
Date of arrival in California
Countries or states visited
Dates in countries or states visited
/
/______
Close contact with person(s) with rash 8-17 days before rash onset?
Yes
No
Unknown
Name
Rash onset date
Relationship
Age (Years)
Same household
1
Yes
No
Unknown
/
/______
Yes
No
Unknown
2
/
/______
Yes
No
Unknown
3
/
/______
Please list other contacts on a separate sheet or use the contact tracing work sheet.
Epi-linked to a lab-confirmed case?
Case name or case ID
Outbreak related
Outbreak location
Yes
No
Unknown
Yes
No
Unknown
Import status
If case is indigenous, is case
If case is imported, describe source
Indigenous
Out-of-state import
Import-linked (linked to imported case)
Endemic
Unknown Source
International Import
Imported virus (viral genetic evidence indicates an imported genotype)
CONTACT INVESTIGATION
Spread Setting (check all that apply)
1
Day care
4
Hospital Ward
7
Home
10
College
13
Church
2
School
5
Hospital ER
8
Work
11
Military
14
International travel
3
Doctor’s office
6
Outpatient hospital clinic
9
Unknown
12
Correctional facility
15
Other
Number of susceptible contacts
Close contacts who have rash 8-17 days after exposure to case (list below)
Yes
No
Unknown
Name
Rash onset date
Relationship
Age (Years)
Same household
Yes
No
Unknown
1
/
/______
Yes
No
Unknown
2
/
/______
Yes
No
Unknown
3
/
/______
Please list other contacts on a separate sheet or use the contact tracing work sheet.
CASE CLASSIFICATION (FOR LHD USE)
CASE CLASSIFICATION (FOR STATE USE ONLY)
Confirmed
Probable
Suspect
Not a case
Unknown
Confirmed
Probable
Suspect
Not a case
Unknown
MEASLES CASE DEFINITION
Clinical case definition: An illness characterized by all the following: (1) a generalized rash lasting greater than or equal to 3 days, (2) a temperature greater
than or equal to 101.0°F (greater than or equal to 38.3°C), and (3) cough, coryza, or conjunctivitis.
Laboratory criteria for diagnosis: Positive serologic test for measles immunoglobulin M antibody; significant rise in measles antibody level by any standard
serologic assay; or isolation of measles virus from a clinical specimen.
Case classification
Suspected: any febrile illness accompanied by rash.
Probable: a case that meets the clinical case definition, has noncontributory or no serologic or virologic testing, and is not epidemiologically linked to a confirmed
case.
Confirmed: a case that is laboratory confirmed or that meets the clinical case definition and is epidemiologically linked to a confirmed case (a laboratory-
confirmed case does not need to meet the clinical case definition).
Page 2 of 2
CDPH 8345 (8/08)
Page of 2