Form Cdph 110b - Confidential Morbidity Report Template - California Department Of Public Health
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1
2State of California—Health and Human Services Agency
California Department of Public Health
CONFIDENTIAL MORBIDITY REPORT
PLEASE NOTE: Only use this form for reporting Tuberculosis.
DISEASE BEING REPORTED
Tuberculosis
Patient Name - Last Name
First Name
MI
Ethnicity (check one)
Hispanic/Latino
Non-Hispanic/Non-Latino
Unknown
Race (check all that apply)
Home Address: Number, Street
Apt./Unit No.
African-American/Black
American Indian/Alaska Native
City
State
ZIP Code
Asian (check all that apply)
Asian Indian
Hmong
Thai
Home Telephone Number
Cell Telephone Number
Work Telephone Number
Cambodian
Japanese
Vietnamese
Chinese
Korean
Other (specify):
Email Address
Primary
English
Spanish
Filipino
Laotian
Language
Other: ______________
Pacific Islander (check all that apply)
Birth Date (mm/dd/yyyy)
Age
Gender
Native Hawaiian
Samoan
Years
M to F Transgender
Male
Guamanian
Other (specify): ________
Months
F to M Transgender
Female
White
Days
Other: ____________
Pregnant?
Est. Delivery Date (mm/dd/yyyy)
Country of Birth
Other (specify): _______________
Unknown
Yes
No
Unknown
Occupation or Job Title
Occupational or Exposure Setting (check all that apply):
Food Service
Day Care
Health Care
Correctional Facility
School
Other (specify): _______________________________________
Date of Onset (mm/dd/yyyy)
Date of First Specimen Collection (mm/dd/yyyy)
Date of Diagnosis (mm/dd/yyyy)
Date of Death (mm/dd/yyyy)
Reporting Health Care Provider
Reporting Health Care Facility
REPORT TO:
Address: Number, Street
Suite/Unit No.
City
State
ZIP Code
Telephone Number
Fax Number
Submitted by
Date Submitted (mm/dd/yyyy)
(Obtain additional forms from your local health department.)
Laboratory Name
City
State
ZIP Code
TUBERCULOSIS (TB)
TB TREATMENT INFORMATION
Status
Mantoux TB Skin Test
Bacteriology/Pathology
Current Treatment (check all that apply)
Please mark positive on smear or culture if any
Active Disease
INH
RIF
PZA
of initial specimens obtained was positive
Confirmed
EMB
Date Placed
Date Read
Suspected
Other: ____________________
(mm/dd/yyyy)
(mm/dd/yyyy)
Date Specimen Collected: _______________
Not done
Infected, No Disease
(mm/dd/yyyy)
Other: ____________________
Results: _______ mm
Pending
Converter*
Not read
Source: _________________________________
Other: ____________________
* For TST, an increase
Interferon Gamma Release Assay (IGRA)
of >10 mm in induration
Smear for acid-fast bacilli:
size during <2 years.
Pos
Neg
Pending
Not done
Date Collected: _______________
Date Treatment Initiated: ______________
(mm/dd/yyyy)
Culture for M. tuberculosis complex:
(mm/dd/yyyy)
Pos
Neg
Pending
Not done
Sites(s)
Specify test name: _____________________
Pulmonary
Pathology suggests TB
Positive
Not done
Extra-Pulmonary
Drug resistance suspected
Rapid Drug Resistance Assay
Results:
Indeterminate
Unknown
Both
INH resistance
Not done
Negative
RIF resistance
Untreated
Chest X-Ray
No INH or RIF resistance detected
Imaging:
Will treat
Chest CT Scan or Other Chest
Nucleic Acid Amplification/PCR Test for
Imaging Study
Unable to contact patient
M. tuberculosis complex
Patient refused treatment
Date Performed: _______________
(mm/dd/yyyy)
Specify test type: _________________________
Other: _____________________
Normal
Referred to: _________________
Pos
Indeterminate
Pending
Results:
Results:
Neg
Not done
Cavitary
Abnormal/Noncavitary
Other test(s): ____________________________
Not done
Remarks:
CDPH 110b (07/16)
(for reporting Tuberculosis)
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