State of California—Health and Human Services Agency

California Department of Public Health

CONFIDENTIAL MORBIDITY REPORT

PLEASE NOTE: ONLY for reporting COVID-19 hospitalizations/deaths/POC testing by HCP - Report to SFDPH within one working day

DISEASE BEING REPORTED: COVID-19 Please write all dates as (mm/dd/yyyy)

Patient Name - Last Name First Name MI Ethnicity (check one)
Hispanic/Latino Non-Hispanic/Non-Latino Unknown
Home Address: Number, Street Apt./Unit No. Race (check all that apply)
African-American/Black
City State ZIP Code American Indian/Alaska Native
Asian (check all that apply)
Home Telephone Number Cell Telephone Number Work Telephone Number Asian Indian Hmong Thai
Cambodian Japanese Vietnamese
Email Address Country of Birth Primary Chinese Korean Other (specify):
English Spanish
Language Filipino Laotian
Other:
Pacific Islander (check all that apply)
Birth Date (mm/dd/yyyy) Age
Years Months Days Native Hawaiian Samoan
Guamanian Other (specify):
Current Gender Identity Sexual Orientation
White
Male Heterosexual or straight Unknown
Other (specify):
Female Bisexual Close contact with a laboratory confirmed COVID-19 case?
Trans male / transman Gay, lesbian, or same gender loving Yes No Unknown
Trans female / transwoman Orientation not listed (specify): ___________________ If Yes, type of contact:
Genderqueer or non-binary Questioning / unsure / client doesn't know Household contact
Identity not listed (specify):________________ Declined to answer Community contact
Declined to answer Any healthcare contact
Gender(s) of sex partners (check all that apply)
Sex Assigned at Birth Male Workplace contact

Male Female Declined to answer Female

Additional Contact Details (if applies)
Trans male / transman
Pregnant?
Trans female / transwoman
Yes No Unknown Genderqueer or non-binary

If Yes, Est. Delivery Date: ______________ Identity not listed (specify):________________

Declined to answer

Congregate setting (check if applies) Occupation or Job Title

Staff Resident Unknown
Assisted Living Facility Skilled Nursing Facility Shelter Healthcare worker In healthcare setting

Correctional Facility Hospital-Based Facility Clinic Housing Status

Other (specify): Stable Unstable Unknown
Name,City of Congregate Setting(s) (if applies):

Reporting Health Care Provider Reporting Health Care Facility REPORT TO:
For Coronavirus Disease- ONLY hospitalization, deaths
Address: Number, Street Suite/Unit No. and point of care testing by health care providers (HCP) to:

San Francisco Department of Public Health

City State ZIP Code
Fax: (628) 217-7599
Email: Include "SECURE" in subject line. Send to
Telephone Number Fax Number cdcontrol@sfdph.org

Email Address: Date Submitted Please submit lab report with CMR

Laboratory Name City State ZIP Code

Continued on next page.

CDPH 110d (2/21) (for reporting COVID-19) Page 1 of 2

State of California—Health and Human Services Agency California Department of Public Health

CONFIDENTIAL MORBIDITY REPORT – COVID-19 (continued)

Patient Name - Last Name First Name MI Birth Date (mm/dd/yyyy)

COVID-19: Hospitalization Status and Diagnostic Testing Diagnosis Date: Clinical Information
Status at Time of Report Complete dates COVID-19 Testing (Complete all that apply) COVID-19 Symptoms (Check all that apply)
where applies
Hospitalized, ICU PCR swab (NP and/or OP) None Fever >100.4F, 38C Subjective fever
Date Hospitalized Chills Rigors Runny nose
Intubated
(if ever hospitalized) Date Specimen(s) Collected Sore throat Cough Shortness of breath
Not Intubated
Difficulty breathing Muscle aches Headache
Hospitalized, non-ICU Positive Indeterminate
Date Discharged Result:
Negative Pending Loss of smell Loss of taste Nausea
Not Hospitalized (if previously hospitalized)
Vomiting Abdominal pain Diarrhea
Deceased Antigen Test name:____________
Date Intubated Dermatologic finding Thromboses (e.g. stroke, DVT, PE)
Date of Death
(if applies) (if ever intubated)
Other (specify): _________________________________________
Date Specimen Collected
Status History
Positive Date of first symptom onset:_________________________________
Yes No Indeterminate
Ever Hospitalized? Result:
Negative Pending
Ever in ICU? Yes No Travel to or reside in an area with sustained, ongoing, community
transmission of SARS-CoV-2?
Ever Intubated? Yes No
Serology Test name:____________ Yes No Unknown
Ever Placed on ECMO? Yes No
If yes, location(s):________________________________________
Respiratory Complications Date Specimen Collected
Other diagnosis or etiology for respiratory condition?
Clinical or Radiologic Clinical or Radiologic Positive Indeterminate
Result: Yes (specify):________________________ No
Evidence of Pneumonia Evidence of ARDS Negative Pending
(check all that apply) (check all that apply)
Chronic Conditions (Check all that apply)
None None Other:___________________________
Clinical Clinical None Unknown Diabetes
Cardiovasc. disease Hypertension Asthma
Radiologic Radiologic Date Specimen Collected
Chronic lung disease Chronic kidney disease Chronic liver disease
Positive Indeterminate Neurological/
Imaging performed (check all that apply) Result: Stroke Cancer
Negative Pending neuro-developemental
Chest X-Ray Immunocompromised Obesity Current smoker
Date Performed Not tested for COVID-19
Former smoker Current e-cigarette or vape use
Chest CT Scan COVID-19 Specific Treatment(s)
Date Performed Other (specify):_____________________________________

Other Chest Imaging Study Vaccination History

Date Performed Drug, Dosage, Route Date Initiated
Received one or more doses of COVID-19 vaccine

Drug, Dosage, Route Date Initiated Yes No Unknown

Date of Dose 1
Type of Vaccine (i.e., Pfizer, Moderna, etc.)
Drug, Dosage, Route Date Initiated
Date of Dose 2

Additional Remarks

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