Ting requirements and reportable diseases on back. DISEASE BEING REPORTED: Patient s Last Name Social Security Number Birth Date First Name/Middle Name (or initial) Month Ethnicity ( Day one) Hispanic/Latino Non-Hispanic/Non-Latino Age Year Race ( one) African-American/Black Address: Number, Street Apt./Unit Number City/Town State Area Code Home Telephone Area Code M Wor.
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How to fill out the CA CDPH 110a (Formerly PM 110) online
Completing the CA CDPH 110a form is essential for reporting certain communicable diseases in California. This guide provides clear and supportive instructions to help you fill out the form online effectively.
Follow the steps to complete the form confidently.
- Click ‘Get Form’ button to obtain the CA CDPH 110a form and open it for editing.
- Begin by filling in the disease being reported. Write the name of the disease in the designated field, ensuring accuracy.
- Enter the patient's last name, followed by their social security number and birth date. Ensure each section is filled correctly to avoid delays.
- Complete the patient's first name and middle name (or initial).
- Select the patient's ethnicity by choosing one option from the designated box regarding Hispanic/Latino status.
- Indicate the patient's age in years and select the appropriate race from the provided list.
- Provide the patient's address, including the number, street, apartment/unit number, city, state, and ZIP code.
- Fill in the home and work telephone numbers with the proper area codes.
- Record the date of onset of the disease by entering the specific day, month, and year.
- If applicable, indicate if the patient is pregnant by selecting ‘Y’ for yes or ‘N’ for no.
- Complete the sections related to sexually transmitted diseases (STD), including the type of STD and its confirmed or suspected status.
- In the TB treatment section, provide details on the current treatment status and the date treatment was initiated.
- Finish by entering any remarks or additional notes that may be relevant for the report.
- Once all fields are completed, you can save changes, download a copy, print the form, or share it as needed.
Complete your CA CDPH 110a form online to ensure accurate reporting of communicable diseases.
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