Read APPENDIX C: CMR FORM AND EXPORT SPECIFICATION text version

Appendix C: CMR Form & Export

APPENDIX C: CMR FORM AND EXPORT SPECIFICATION Appendix C contains the CMR Form referenced within the Web-CMR Business Requirements (Appendix A) and the variables contained within the currently utilized AVSS CMR Export.

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State of California--Health and Human Services Agency

Appendix C: CMR Form & Export

Department of Health Services

CONFIDENTIAL MORBIDITY REPORT

NOTE: For STD, Hepatitis, or TB, complete appropriate section below. Special reporting requirements and reportable diseases on back.

DISEASE BEING REPORTED: ___________________________________________________________________________________

Patient's Last Name Social Security Number

Ethnicity ( one)

­

First Name/Middle Name (or initial) Birth Date

Month Day

­

Year

Hispanic/Latino Non-Hispanic/Non-Latino Age

Race ( one)

African-American/Black Address: Number, Street Apt./Unit Number Asian/Pacific Islander ( one): Asian-Indian Cambodian City/Town State ZIP Code Chinese Filipino Area Code Home Telephone Gender M F Pregnant? Y N

Unk

Japanese Korean Laotian Samoan Vietnamese

Estimated Delivery Date

Month Day Year

Guamanian Hawaiian

­

Area Code

­

Work Telephone

Other:________________________ Native American/Alaskan Native Correctional facility Other _________________________ White: __________________________ Other: __________________________

­

DATE OF ONSET

Month Day Year

­

Patient's Occupation/Setting Food service Day care Health care School

Reporting Health Care Provider

REPORT TO

Reporting Health Care Facility

DATE DIAGNOSED

Month Day Year

Address

City

State

ZIP Code

DATE OF DEATH

Month Day Year

Telephone Number

Fax

(

)

(

)

(Obtain additional forms from your local health department.)

Submitted by

Date Submitted (Month/Day/Year)

SEXUALLY TRANSMITTED DISEASES (STD)

Syphilis Syphilis Test Results

Primary (lesion present) Late latent > 1 year RPR Titer:__________ Secondary Late (tertiary) VDRL Titer:__________ Early latent < 1 year Congenital FTA/MHA: Pos Neg Latent (unknown duration) CSF-VDRL: Pos Neg Neurosyphilis Other:_________________ Gonorrhea Chlamydia PID (Unknown Etiology) Urethral/Cervical Urethral/Cervical Chancroid PID PID Non-Gonococcal Urethritis Other: ____________________ Other: _____________ STD TREATMENT INFORMATION Untreated Treated (Drugs, Dosage, Route): Date Treatment Initiated Will treat Month Day Year Unable to contact patient ____________________________ Refused treatment ____________________________ Referred to: _________________ TUBERCULOSIS (TB) Status Active Disease Confirmed Suspected Infected, No Disease Convertor Reactor Site(s) Pulmonary Extra-Pulmonary Both REMARKS Mantoux TB Skin Test

Month Day Year

VIRAL HEPATITIS

Hep A Hep B Acute Chronic Hep C Acute Chronic

anti-HAV IgM HBsAg anti-HBc anti-HBc IgM anti-HBs anti-HCV PCR-HCV

Pos

Neg

Not Pend Done

Hep D (Delta) anti-Delta Other: ______________ Suspected Exposure Type Blood Other needle

transfusion Child care

Sexual Household exposure contact contact Other: ________________________________ TB TREATMENT INFORMATION Current Treatment INH RIF PZA EMB Other: ____________

Month Day Year

Bacteriology

Month Day Year

Date Performed

Date Specimen Collected

Pending Results:______________ mm Not Done Chest X-Ray

Date Performed

Month Day Year

Normal Cavitary

Pending Not done Abnormal/Noncavitary

Date Treatment Source _______________________________________ Initiated Smear: Pos Neg Pending Not done Culture: Pos Neg Pending Not done Untreated Will treat Other test(s) ___________________________________ Unable to contact patient Refused treatment _______________________________________ Referred to: _____________________

PM 110 (8/05) (Edited 9/05)

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Appendix C: CMR Form & Export

Title 17, California Code of Regulations (CCR), §2500, §2593, §2641­2643, and §2800­2812

Reportable Diseases and Conditions*

§2500. REPORTING TO THE LOCAL HEALTH AUTHORITY. §2500(b) It shall be the duty of every health care provider, knowing of or in attendance on a case or suspected case of any of the diseases or conditions listed below, to report to the local health officer for the jurisdiction where the patient resides. Where no health care provider is in attendance, any individual having knowledge of a person who is suspected to be suffering from one of the diseases or conditions listed below may make such a report to the local health officer for the jurisdiction where the patient resides. §2500(c) The administrator of each health facility, clinic or other setting where more than one health care provider may know of a case, a suspected case or an outbreak of disease within the facility shall establish and be responsible for administrative procedures to assure that reports are made to the local health officer. §2500(a)(14) "Health care provider" means a physician and surgeon, a veterinarian, a podiatrist, a nurse practitioner, a physician assistant, a registered nurse, a nurse midwife, a school nurse, an infection control practitioner, a medical examiner, a coroner, or a dentist. URGENCY REPORTING REQUIREMENTS [17 CCR §2500 (h) (i)] = Report immediately by telephone (designated by a in regulations). = Report immediately by telephone when two or more cases or suspected cases of foodborne disease from separate households are suspected to have the same source of illness (designated by a in regulations). FAX = Report by FAX, telephone, or mail within one working day of identification (designated by a + in regulations).

= All other diseases/conditions should be reported by FAX, telephone, or mail within seven calendar days of identification.

REPORTABLE COMMUNICABLE DISEASES §2500(j)(1), §2641­2643

FAX FAX FAX

FAX

FAX FAX

FAX

FAX

FAX

FAX

FAX

FAX FAX FAX

FAX FAX

Acquired Immune Deficiency Syndrome (AIDS) (HIV infection only: see "Human Immunodeficiency Virus") Amebiasis Anisakiasis Anthrax Babesiosis

Botulism (Infant, Foodborne, Wound)

Brucellosis

Campylobacteriosis

Chancroid

Chlamydial Infections

Cholera

Ciguatera Fish Poisoning

Coccidioidomycosis Colorado Tick Fever Conjunctivitis, Acute Infectious of the Newborn, Specify Etiology Cryptosporidiosis Cysticercosis Dengue Diarrhea of the Newborn, Outbreaks Diphtheria Domoic Acid Poisoning (Amnesic Shellfish Poisoning) Echinococcosis (Hydatid Disease) Ehrlichiosis Encephalitis, Specify Etiology: Viral, Bacterial, Fungal, Parasitic Escherichia coli O157:H7 Infection Foodborne Disease Giardiasis Gonococcal Infections Haemophilus influenzae Invasive Disease

Hantavirus Infections

Hemolytic Uremic Syndrome

Hepatitis, Viral Hepatitis A Hepatitis B (specify acute case or chronic) Hepatitis C (specify acute case or chronic) Hepatitis D (Delta) Hepatitis, other, acute Human Immunodeficiency Virus (HIV) (§2641­2643): reporting is NON-NAME (see www.dhs.ca.gov/aids) Kawasaki Syndrome (Mucocutaneous Lymph Node Syndrome) Legionellosis Leprosy (Hansen Disease) Leptospirosis Listeriosis Lyme Disease Lymphocytic Choriomeningitis Malaria Measles (Rubeola) Meningitis, Specify Etiology: Viral, Bacterial, Fungal, Parasitic Meningococcal Infections Mumps Non-Gonococcal Urethritis (Excluding Laboratory Confirmed Chlamydial Infections)

FAX FAX FAX FAX FAX

FAX

FAX FAX FAX FAX

FAX FAX FAX

FAX

FAX FAX FAX

Paralytic Shellfish Poisoning

Pelvic Inflammatory Disease (PID)

Pertussis (Whooping Cough)

Plague, Human or Animal

Poliomyelitis, Paralytic

Psittacosis

Q Fever

Rabies, Human or Animal Relapsing Fever

Reye Syndrome

Rheumatic Fever, Acute

Rocky Mountain Spotted Fever

Rubella (German Measles)

Rubella Syndrome, Congenital

Salmonellosis (Other than Typhoid Fever)

Scombroid Fish Poisoning

Severe Acute Respiratory Syndrome (SARS)

Shigellosis Smallpox (Variola) Streptococcal Infections (Outbreaks of Any Type and Individual Cases in Food Handlers and Dairy Workers Only)

Swimmer's Itch (Schistosomal Dermatitis)

Syphilis

Tetanus

Toxic Shock Syndrome

Toxoplasmosis

Trichinosis Tuberculosis Tularemia Typhoid Fever, Cases and Carriers Typhus Fever Varicella (deaths only) Vibrio Infections Viral Hemorrhagic Fevers (e.g., Crimean-Congo, Ebola, Lassa and Marburg viruses)

Water-associated Disease

West Nile Virus (WNV) Infection

Yellow Fever Yersiniosis OCCURRENCE of ANY UNUSUAL DISEASE OUTBREAKS of ANY DISEASE (Including diseases not listed in §2500). Specify if institutional and/or open community.

REPORTABLE NONCOMMUNICABLE DISEASES AND CONDITIONS §2800­2812 and §2593(b)

Disorders Characterized by Lapses of Consciousness Cancer (except (1) basal and squamous skin cancer unless occurring on genitalia, and (2) carcinoma in-situ and CIN III of the cervix) Pesticide-related illness or injury (known or suspected cases)**

LOCALLY REPORTABLE DISEASES (If Applicable):

This form is designed for health care providers to report those diseases mandated by Title 17, California Code of Regulations (CCR). Failure to report is a misdemeanor (Health and Safety Code §120295) and is a citable offense under the Medical Board of California's Citation and Fine Program (Title 16, CCR, §1364.10 and 1364.11). ** Failure to report is a citable offense and subject to civil penalty ($250) (Health and Safety Code §105200).

*

PM 110 (8/05) (Edited 9/05)

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CMR464

Appendix C: CMR Form & Export

Page 1 of 2

Layout For #CMRG464=Y2K 464 BYTE CMR FLAT FILE

LEN START 11 1 6 8 20 15 1 10 11 20 1 3 25 20 5 12 15 2 6 15 3 3 10 10 10 10 10 7 1 4 10 10 4 1 12 18 26 46 61 62 72 83 103 104 107 132 152 157 169 184 186 192 207 210 213 223 233 243 253 263 270 271 275 285 295 299 STOP FIELD 11 ID 17 ICDA 25 45 60 61 71 82 DISEASE LNAM FNAM MI DOB SSN DESCRIPTION CASE ID ASSIGNED BY AVSS ICD-9 CODE AVSS DISEASE NAME PATIENT'S LAST NAME FIRST NAME MIDDLE INITIAL DATE OF BIRTH SOCIAL SECURITY NUMBER RACE GENDER AGE STREET ADDRESS CITY ZIP HOME TELEPHONE COUNTY OF RESIDENCE CODE FOR COUNTY OF RESIDENCE CENSUS TRACT OCCUPATION CODE FOR STATE OF BIRTH REPORTER TYPE DATE SUBMITTED TO STATE DATE OF ONSET DATE OF DIAGNOSIS DATE OF DEATH DATE OF RECEIPT MONTH/YEAR PATIENT ARRIVED IN U.S. COUGH/SPUTUM PRODUCTION BACTERIOLOGY CULTURE DATE BACTERIOLOGY SUBMITTED ESTIMATED DELIVERY DATE anti-Delta LAB TEST RESULT HISPANIC FO 4YYCCNNNNNN ALPHA FROM AVSS ALPHA FROM AVSS FREE TEXT FREE TEXT FREE TEXT MM/DD/CCYY NNN-NN-NNNN COMBINES RACE1 F,M,U NNN,UNK FREE TEXT FREE TEXT NNNNN VARIABLE NUMBER ALPHA FROM AVSS NN NNNNNN FREE TEXT ALPHA FROM AVSS BB,MIL,PRV,PUB MM/DD/CCYY MM/DD/CCYY MM/DD/CCYY MM/DD/CCYY MM/DD/CCYY MM/CCYY N,Y,U NEG,NOTD,PEND,P MM/DD/CCYY MM/DD/CCYY NEG,NOTD,PEND,P N,Y,U

102 RACE 103 SEX 106 131 151 156 168 183 185 191 206 209 212 222 232 242 252 262 269 270 274 284 294 298 299 AGE ADDRESS CITY ZIP PHONE COUNTY ICOUNTY CTRACT WORK ICOUNTRY RPTRTYPE DATSENT DATON DATDX DATDTH DATREC ARRIVE COUGH CULTURE DATBACTR DATDEL DELTA ETHNICITY

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http://www.avss.ucsb.edu/layouts/cmr464.htm

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CMR464

Appendix C: CMR Form & Export

Page 2 of 2

5 5 4 4 4 4 4 4 2 4 8 8 4 1 8 1 8 12 12 12 4 4 12 3 6 3 3 12 4

300 305 310 314 318 322 326 330 334 336 340 348 356 360 361 369 370 378 390 402 414 418 422 434 437 443 446 449 461

304 EXPOSURE 309 GCCOMP 313 HAVIGM 317 321 325 329 333 335 339 347 HBC HBCIGM HBS HBSAG HCV IRACE NOC OUTDIS

HOW PATIENT EXPOSED TO DISEASE COMPLICATION OF GC/CHLAMYDIA anti-HAV IgM LAB TEST RESULT anti-HBc LAB TEST RESULT anti-HBc IgM LAB TEST RESULT anti-HBs LAB TEST RESULT HBsAG LAB TEST RESULT anti-HCV LAB TEST RESULT RACE CODE DISEASE OUTBREAK NUMBER OF CASES OUTBREAK DISEASE NAME ASSIGNED OUTBREAK NUMBER PCR-HCV PREGNANT PATIENT'S RACE REPORTABLE DISEASE STATUS REPORTER REPORTER'S TELEPHONE NUMBER REPORTER NAME SALMONELLOSIS SEROTYPE TUBERCULIN SKIN TEST BACTERIOLOGY SMEAR ANIMAL SPECIES PATIENT'S RESIDENCE STATE TUBERCULOSIS SITE MILLIMETERS INDURATION TUBERCULOSIS STATUS WORK TELEPHONE X-RAY RESULTS

BLDTR,CHLDC,HSH CONJ,NONE,OTHR NEG,NOTD,PEND,P NEG,NOTD,PEND,P NEG,NOTD,PEND,P NEG,NOTD,PEND,P NEG,NOTD,PEND,P NEG,NOTD,PEND,P A1-A9,B,H,N,O,P1-P NNNN ALPHA FROM AVSS ALPHANUMERIC NEG,NOTD,PEND,P N,Y,U ALPHA FROM AVSS N,Y ALPHA FROM AVSS VARIABLE NUMBER FREE TEXT ALPHA FROM AVSS CONV,REAC,UNK NEG,NOTD,PEND,P FREE TEXT ALPHA FROM AVSS NONPUL,PULM,UN NNN,UNK DEF,SUS,UNK VARIABLE NUMBER CAV,NCAV,UNK

355 OUTNUM 359 PCRHCV 360 PREGNANT 368 RACE1 369 REPDIS 377 389 401 413 417 421 433 436 442 445 REPORTER RPTRPHON RPTRSPEC SEROTYPE SKINTEST SMEAR SPECIES STATE TBSITE TBSIZE

448 TBSTAT 460 WPHONE 464 XRAY

Updated January 9, 2003 by RL Williams

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APPENDIX C: CMR FORM AND EXPORT SPECIFICATION

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