|
DISEASE |
FORM NAME |
|
Amebiasis |
Parasite
Epidemiologic Case History |
|
Anaplasmosis |
Ehrlichiosis / Anaplasmosis Case Report |
|
Anthrax
|
Anthrax
(Human) Case Report |
|
|
Suspected Cutaneous
Anthrax Case Investigation Form |
|
|
Suspected
Inhalation Anthrax Case Investigation Form |
|
|
Anthrax
Post-Exposure Epidemiologic Investigation Form |
|
Avian Influenza, Human |
California
Case Report Form for Laboratory-Confirmed Avian (H5N1)
Influenza |
|
|
Avian
(H5N1) Influenza Suspect Case Screening Form |
|
|
Specimen
Submittal Form for Suspect Avian Influenza A (H5N1) |
|
Babesiosis |
Outbreak/Unusual Disease Report |
|
Bioterrorism-Unspecified Illness Outbreak |
Gastrointestinal Illness
Case Investigation Form |
|
|
Fever/Rash Illness
Case Investigation Form |
|
|
Neurological
Illness Case Investigation Form |
|
|
Respiratory Illness
Case Investigation Form |
|
Botulism
|
Botulism
Case Report |
|
|
Suspect Botulism
Intake and Checklist |
|
|
Specimen Submission Guidelines for Suspected Botulism |
|
Brucellosis
|
Brucellosis (Undulant Fever), Q Fever, Tularemia
Case Report |
|
Chicken Pox (Hospitalized Cases and Deaths)
|
Varicella (Chicken Pox)
Hospitalized Case Report |
|
|
Varicella Death Investigation Worksheet |
|
|
Instructions
(for the Varicella Death Investigation Worksheet) |
|
Cholera
|
Cholera &
Other Vibrio Illness Surveillance Report |
|
Ciguatera Fish Poisoning |
Outbreak/Unusual Disease Report |
|
Colorado Tick Fever |
Outbreak/Unusual Disease Report |
|
Creutzfeldt-Jakob Disease (CJD)
and Transmissible Spongiform Encephalopathy (TSE) |
Creutzfeldt-Jakob Disease
(CJD) and Transmissible Spongiform Encephalopathy (TSE) Case
Report
|
|
Cryptosporidiosis |
Parasite
Epidemiologic Case History |
|
Cysticercosis (Taeniasis) |
Cysticercosis
/ Taeniasis Case Report |
|
|
Cysticercosis (Taeniasis) Contact Work Sheet |
|
|
Cysticercosis
Patient History Form - Specimen Submittal |
|
|
Cysticercosis Finger Prick Specimen Collection Protocol
|
|
Dengue
(Break-Bone Fever) |
Dengue
Case Report |
|
Diphtheria
|
Diphtheria
Case Report |
|
Domoic Acid (Amnesic Shellfish) Poisoning |
Outbreak/Unusual Disease Report |
|
Ehrlichiosis
|
Ehrlichiosis / Anaplasmosis Case Report |
|
Foodborne
Disease Outbreak |
Investigation of a Foodborne Outbreak |
|
Giardiasis |
Parasite
Epidemiologic Case History |
|
Haemophilus Influenzae
|
Invasive
Haemophilus Influenzae Disease Case Report |
|
|
Haemophilus Influenzae Type B Vaccine and Extended
Information Worksheet |
|
Hansen's
disease (Leprosy) |
Leprosy
Surveillance |
|
|
Leprosy
Case/Contact Surveillance |
|
Hantavirus
Infections |
Hantavirus Infections Case Report |
|
|
Hantavirus
Pulmonary Syndrome Screening Form |
|
Hemolytic
Uremic Syndrome (HUS) |
E. coli 0157, Other STEC, Shiga Toxin Positive Feces,
and/ or HUS Case Report |
|
Hepatitis, viral
|
Viral
Hepatitis Case Report |
|
|
Transfusion
Associated Hepatitis Case Record |
|
Hepatitis
B, Perinatal |
Perinatal Hepatitis B Case Report |
|
|
Confidential HBsAg+ Case / Household Management Report |
|
|
Post-Exposure Prophylaxis (PEP) Errors |
|
Influenza,
Avian |
Avian
(H5N1) Influenza Suspect Case Screening Form |
|
|
California
Case Report Form for Laboratory-Confirmed Avian (H5N1)
Influenza |
|
|
Specimen
Submittal Form for Suspect Avian Influenza A (H5N1) |
|
Influenza (Human) Fatal |
Influenza Fatality Case Report
Form |
|
|
Influenza Fatality Case Supplemental Form (ACDC USE
ONLY) |
|
Legionellosis
|
Legionellosis Case Report |
|
Leprosy (Hansen's disease) |
Leprosy Surveillance |
|
|
Leprosy Case/Contact Surveillance |
|
Leptospirosis
|
Leptospirosis Case Report |
|
Listeriosis
(Perinatal and Nonperinatal) |
Listeriosis Case
Report (ACDC USE ONLY) |
|
|
Listeriosis Case Abstraction Form
(ACDC USE ONLY) |
|
Lyme Disease
|
Lyme Disease Case Report |
|
Malaria
|
Malaria Case Report |
|
Measles (Rubeola)
|
Measles
(Rubeola)
Case Report |
|
Meningococcal Infections |
Meningococcal Disease Case Report |
|
|
Meningococcal Disease Contact Roster
|
|
Mumps |
Mumps Case Report |
|
Outbreak - Foodborne Diseases |
Investigation of a Foodborne Outbreak |
|
Outbreak - General or Non-Health Care Facility |
Outbreak/Unusual Disease Report |
|
Outbreak - Health Care Facility (HF) |
CD Outbreak
Investigation Acute Health Care Facility
(ACDC USE ONLY) |
|
|
CD Outbreak
Investigation Sub-Acute Health Care Facility
(Instructions) |
|
|
Sample Line List - Respiratory
Outbreak Line List for Residents and Staff |
|
|
Sample Line List -
Scabies Outbreak |
|
|
Sample Line List - Viral
Gastroenteritis Outbreak |
|
Outbreak-Norovirus |
Norovirus
Outbreak Submittal Form For Positive Specimens/ RNA Extract |
|
Outbreak - Respiratory |
Initial Report:
Initial outbreak form for school/daycare settings and worksheet |
|
|
Final Report:
Acute Febrile
Respiratory Illness and / or Infectious Pneumonia
Community-Based Settings Outbreak Report Form |
|
|
Acute Febrile
Respiratory Illness and / or Infectious Pneumonia
Congregate-Living Settings Outbreak Report Form |
|
Outbreak - Waterborne Diseases |
Waterborne Diseases Outbreak Report |
|
Paralytic Shellfish Poisoning |
Outbreak/Unusual Disease Report |
|
Paratyphoid Fever |
Typhoid and Paratyphoid Fever
Case Report |
|
Pertussis
(Whooping Cough) |
Pertussis Case Report |
|
|
Pertussis Death Worksheet |
|
Plague
|
Plague
(Human) Case Report |
|
Pneumococcal, Invasive Disease
|
Invasive Pneumococcal Disease Report Form |
|
Poliomyelitis
|
Poliomyelitis Case Report |
|
Psittacosis |
Psittacosis Case Report |
|
Q-Fever
|
Brucellosis (Undulant Fever), Q Fever, Tularemia
Case Report |
|
Rabies
|
Human Rabies Case Report |
|
|
Rabies Exposure Form For
Healthcare Workers |
|
Relapsing Fever
|
Relapsing Fever
Case Report |
|
Rocky Mountain Spotted Fever |
Spotted Fever Rickettsioses Case Report |
|
Rubella (German Measles,
3-day measles) |
Rubella
(German Measles)
Case Report |
|
Rubella Syndrome, Congenital |
Congenital Rubella Syndrome Case Report |
|
Salmonellosis |
Salmonellosis |
|
SARS (Severe Acute Respiratory Syndrome) |
SARS
Domestic Case Reporting
Form |
|
Scabies (atypical or crusted in a non-health facility) |
Outbreak/Unusual Disease Report |
|
Scombroid Fish Poisoning |
Outbreak/Unusual Disease Report |
|
Shiga Toxin-producing Escherichia coli (STEC) |
E. coli 0157, Other STEC, Shiga Toxin Positive Feces,
and/ or HUS Case Report |
|
Shigellosis |
Shigellosis |
|
Smallpox (Variola) |
Worksheet: Evaluating Patients for Smallpox |
|
|
Smallpox Post-Event Surveillance Form |
|
|
Instructions
(for the Smallpox Surveillance Form) |
|
Staphylococcus aureus Infection, Severe |
Severe Staphylococcus aureus Infection in a Previously Health
Person Case Report |
Streptococcal Group A,
Invasive
(Including Streptococcal Toxic Shock Syndrome and
Necrotizing Fasciitis) |
Invasive Group A Streptococcal Disease
(IGAS) Case Report |
|
Streptococcus pneumoniae, Invasive |
Invasive Pneumococcal Disease Report Form |
|
Tetanus
|
Tetanus Surveillance Worksheet |
|
|
Instructions
(for the Tetanus Surveillance Worksheet |
|
|
Supplemental injecting Drug Use Questionnaire for Tetanus Cases |
|
Toxic Shock Syndrome
(Staphylococcal) |
Toxic Shock Syndrome Case Report |
|
Trichinosis |
Trichinosis Case Report |
|
Tularemia
(Rabbit Fever) |
Tularemia Case Report |
|
Typhoid Fever, Acute |
Typhoid and Paratyphoid Fever
Case Report |
|
|
Release of Acute or Convalescent Typhoid Fever Case |
|
Typhoid Fever, Carrier |
Typhoid Carrier Agreement
(English &
Spanish) |
|
|
Typhoid Carrier Semi-Annual Report |
|
|
Typhoid Carrier Register -- Semi-Annual Update |
|
|
Release of Chronic Typhoid Carrier |
|
|
Typhoid Carrier Case Report |
|
Typhus Fever |
Typhus and Other Non-Spotted Fever Rickettsioses Case Report |
|
Vaccine Adverse Event Report (VAERS) |
Vaccine Adverse Event Report
(VAERS) |
|
Varicella
(Chickenpox-Hospitalized
Cases and Deaths)
|
Varicella
(Chicken Pox) Hospitalized
Case Report |
|
|
Varicella Death Investigation Worksheet |
|
|
Instructions
(for the Varicella Death Investigation Worksheet) |
|
Vibriosis |
Cholera & Other Vibrio Illness Surveillance Report |
|
Waterborne Disease Outbreak |
Waterborne Diseases Outbreak Report |
|
West Nile Virus (WNV) Infection |
West
Nile Virus (WNV) Infection Case History Report Form |
|
|
West Nile Virus
(WNV) Supplemental Investigation Form |
|
|
West Nile Virus (WNV) Active Surveillance Laboratory Submittal
Form |
|
Whooping Cough
(Pertussis) |
Pertussis Case Report |
|
Yellow Fever |
Yellow
Fever Case Report |
|
Yersiniosis
|
Yersiniosis
Form |
|
|
|
|
|
|
|
|
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