Follow the steps to complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. Begin by entering the sending facility's name and address in the designated fields. Include the first and last names of both the patient and the individual completing the form.
3. Fill in the contact information, including the telephone number and fax number of the sending facility, as well as the name of the receiving facility.
4. Record the patient’s date of birth and medical record number. If applicable, provide the names and contact information for any alternate contacts.
5. Indicate whether the patient has a positive culture for any multidrug-resistant organisms (MDROs) or other organisms of epidemiological significance. Check the appropriate boxes provided and ensure to send a copy of the culture report with susceptibilities to the receiving facility.
6. Answer the questions regarding the patient's current symptoms, isolation status, and antibiotic treatment. If the patient is currently in isolation, specify the type of isolation required.
7. Document the patient's vaccination history by entering the dates and types of vaccinations administered, along with any known lot numbers or brands.
8. At the end of the form, input the name of the person completing the form followed by their signature. Additionally, note the start date and anticipated stop date for any treatments.
9. Lastly, review all the information entered for accuracy. Save your changes, then choose to download, print, or share the form as needed.

Get started on completing the CA CDPH Interfacility Infection Control Transfer Form online today.