The California PM110 form is a crucial document used by healthcare providers to report specific communicable diseases and conditions to local health authorities. This form ensures that vital health information is communicated effectively, helping to protect public health and manage disease outbreaks. If you need to fill out the PM110 form, please click the button below for assistance.
The California PM110 form serves as a vital tool for health care providers in the state, ensuring that critical health information is accurately reported and monitored. This confidential morbidity report is specifically designed for documenting cases of communicable diseases, such as sexually transmitted infections, hepatitis, and tuberculosis. By requiring detailed patient information—including demographics, diagnosis dates, and treatment status—the form facilitates timely and effective public health responses. It outlines specific reporting requirements for various diseases, emphasizing the importance of swift action in cases of urgency. Additionally, the PM110 form mandates that health care providers report not only confirmed cases but also suspected instances, thereby enhancing disease surveillance and control efforts. With its structured sections, the form allows for the systematic collection of data that can inform public health policies and interventions, ultimately contributing to the well-being of the community. Understanding the nuances of this form is essential for health care professionals, as failure to comply with reporting obligations can lead to legal repercussions. Thus, the PM110 form stands as a cornerstone in California’s public health landscape, bridging the gap between health care providers and health authorities.
State of California—Health and Human Services AgencyDEpartment of Public Health
CONFIDENTIAL MORBIDITY REPORT
NOTE: For STD, Hepatitis, or TB, complete appropriate section below. Special reporting requirements and reportable diseases onback.
DISEASE BEING REPORTED:___________________________________________________________________________________
Patient’s Last Name
Social Security Number
Ethnicity (✓ one)
–
❒ Hispanic/Latino
❒ Non-Hispanic/Non-Latino
Birth Date
Age
First Name/Middle Name (or initial)
Race (✓ one)
Month
Day
Year
❒ African-American/Black
❒ Asian/Pacific Islander (✓ one):
Address: Number, Street
Apt./Unit Number
❒ Asian-Indian
❒ Japanese
❒ Cambodian
❒ Korean
City/Town
State
ZIP Code
❒ Chinese
❒ Laotian
❒ Filipino
❒ Samoan
❒ Guamanian
❒ Vietnamese
Estimated Delivery Date
Area Code
Home Telephone
Gender
Pregnant?
❒ Hawaiian
M
F
Y
N
Unk
❒ Other:________________________
❒ Native American/Alaskan Native
Work Telephone
Patient’s Occupation/Setting
❒ White: __________________________
❒Food service
❒Day care
❒Correctional facility
❒Health care
❒School
❒Other _________________________
❒ Other: __________________________
DATE OF ONSET
Reporting Health Care Provider
REPORT TO
Reporting Health Care Facility
DATE DIAGNOSED
Address
City
DATE OF DEATH
Telephone Number
Fax
(
)
Submitted by
Date Submitted
(Month/Day/Year)
(Obtain additional forms from your local health department.)
SEXUALLY TRANSMITTED DISEASES (STD)
VIRAL HEPATITIS
Not
Syphilis
Syphilis Test Results
❒ Hep A
Pos
Neg
Pend
Done
❒ Primary (lesion present)
❒Late latent > 1 year
❒ RPR
Titer:__________
anti-HAV IgM
❒
❒ Secondary
❒Late (tertiary)
❒ VDRL
❒ Hep B
HBsAg
❒ Early latent < 1 year
❒Congenital
❒ FTA/MHA:
❒ Pos
❒ Neg
❒ Acute
anti-HBc
❒ Latent (unknown duration)
❒ CSF-VDRL:
❒ Chronic
anti-HBc IgM
❒ Neurosyphilis
❒ Other:_________________
anti-HBs
Gonorrhea
Chlamydia
❒ PID (Unknown Etiology)
❒ Hep C
anti-HCV
❒ Urethral/Cervical
❒ Chancroid
PCR-HCV
❒ PID
❒ Non-Gonococcal Urethritis
❒ Other: ____________________
❒ Other: _____________
❒ Hep D (Delta)
anti-Delta
STD TREATMENT INFORMATION
❒ Untreated
❒ Other: ______________
❒ Treated(Drugs,Dosage,Route):
Date Treatment Initiated
❒ Will treat
Suspected Exposure Type
❒ Unable to contact patient
____________________________
❒ Blood
❒Other needle
❒Sexual
❒ Household
❒ Refused treatment
transfusion
exposure
contact
❒ Referred to:_________________
❒Child care
❒Other: ________________________________
TUBERCULOSIS (TB)
TB TREATMENT INFORMATION
Status
Mantoux TB Skin Test
Bacteriology
❒ Current Treatment
❒ Active Disease
Month Day
❒ INH
❒ RIF
❒ PZA
❒ Confirmed
❒ EMB
❒ Other:____________
❒ Suspected
Date Performed
Date Specimen Collected
❒ Infected, No Disease
❒ Pending
Date Treatment
❒ Convertor
Results:______________ mm ❒ Not Done
Source _______________________________________
Initiated
❒ Reactor
Smear:
❒Pos
❒Neg
❒Pending
❒Not done
Chest X-Ray Month
Culture:
Site(s)
❒ Pulmonary
Other test(s) ___________________________________
❒ Extra-Pulmonary
❒Normal
❒Pending ❒Not done
❒Both
❒Cavitary
❒Abnormal/Noncavitary
_______________________________________
❒ Referred to:_____________________
REMARKS
PM 110 (revised 12/08/09)
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Completing the California PM110 form is a crucial step in reporting specific diseases to health authorities. This form must be filled out accurately and submitted promptly to ensure public health safety. Following these steps will help you navigate the process efficiently.
What is the California PM110 form?
The California PM110 form is a Confidential Morbidity Report used by health care providers to report specific communicable diseases, including sexually transmitted diseases (STDs), viral hepatitis, and tuberculosis (TB). It ensures that health authorities receive timely information about diseases that pose a public health risk, allowing for appropriate responses and interventions.
Who is required to complete the PM110 form?
Any health care provider who is aware of or is attending to a case or suspected case of a reportable disease must complete the PM110 form. This includes physicians, nurses, and other medical professionals. In the absence of a health care provider, any individual with knowledge of a suspected case can report it to the local health authority.
What diseases must be reported using the PM110 form?
The PM110 form is specifically designed for reporting a range of communicable diseases, including but not limited to, syphilis, gonorrhea, chlamydia, hepatitis A, B, and C, and tuberculosis. A detailed list of reportable diseases is included in the form and is governed by California's Title 17 regulations.
How quickly must a report be submitted after identifying a reportable disease?
The urgency of reporting varies by disease. For many reportable diseases, the form must be submitted within one working day of identification. However, certain conditions, such as outbreaks or foodborne illnesses, may require immediate reporting by telephone. It's crucial to follow the specific reporting guidelines outlined in the regulations.
What information is required on the PM110 form?
The PM110 form requires comprehensive patient information, including the patient's name, social security number, date of birth, ethnicity, and contact details. Additionally, it requires details about the disease being reported, the health care provider's information, and any relevant test results. This information is vital for effective public health monitoring and response.
What happens if a health care provider fails to report a disease?
Failure to report a reportable disease using the PM110 form can result in legal consequences. Under California law, it is considered a misdemeanor, and violators may face fines or other penalties. Reporting is not only a legal obligation but also a crucial component of protecting public health.
Where can health care providers obtain additional PM110 forms?
Health care providers can obtain additional copies of the PM110 form from their local health department. Many local health departments also provide resources and guidance on completing the form and understanding reporting requirements for various diseases.
Filling out the California PM110 form requires attention to detail. One common mistake is leaving out the patient's last name. This information is crucial for identification and processing. Without it, the report may be deemed incomplete, leading to delays in addressing the health issue at hand.
Another frequent error is failing to accurately indicate the patient's ethnicity. Selecting the wrong category can lead to misinterpretation of data and affect public health responses. Make sure to check the appropriate box carefully to ensure the information is correct.
Many people also overlook the date of onset of the disease. This date is vital for tracking the spread of illnesses and determining the appropriate response. If this field is left blank or filled out incorrectly, it can hinder the health department's efforts to manage outbreaks effectively.
In addition, some individuals mistakenly provide an incorrect or incomplete address for the patient. This can complicate follow-up procedures and impact the ability to reach the patient for further treatment or information. Always double-check the address before submission.
Lastly, not including the reporting health care provider's information is a significant oversight. This information is necessary for communication and follow-up. Ensure that the provider's name, facility, and contact details are clearly stated to facilitate prompt action from health authorities.
The California PM110 form is an essential document used for reporting various communicable diseases to local health authorities. Alongside this form, several other documents play a crucial role in ensuring comprehensive disease surveillance and reporting. Below is a list of these documents, each serving a specific purpose in public health reporting.
These documents collectively enhance the ability of health care providers and public health officials to monitor and respond to communicable diseases effectively. By ensuring accurate and timely reporting, they play a vital role in safeguarding community health.
The California PM110 form is a critical document used for reporting certain communicable diseases and conditions. There are several other forms and documents that serve similar purposes in public health reporting. Below is a list of eight documents that share similarities with the PM110 form, along with explanations of how they are alike.
When filling out the California PM110 form, it is crucial to follow specific guidelines to ensure accuracy and compliance. Here are six important do's and don'ts to consider:
Following these guidelines will help ensure that the reporting process is smooth and compliant with California regulations.
This form is used for a variety of reportable diseases, including tuberculosis and viral hepatitis, not just STDs.
Any health care provider, including nurses and physician assistants, is authorized to complete this form.
The PM110 form is designed to be confidential, ensuring that patient information is protected.
Completing this form is mandatory for health care providers who encounter reportable diseases.
This form is applicable statewide, regardless of whether the location is urban or rural.
While prompt reporting is encouraged, there are specific timelines outlined for different diseases.
Patient demographics, including age and ethnicity, are essential components of the form.
While electronic submission is encouraged, specific regulations dictate the method of reporting for certain diseases.
Suspected cases also require reporting, ensuring public health safety.
Failure to report can lead to civil penalties and is considered a misdemeanor under California law.
Filling out and using the California PM110 form is a critical responsibility for health care providers. Here are five key takeaways to keep in mind: