Get Ca Cdph 110d 2020-2026

The CA CDPH 110d form is specifically designed for reporting COVID-19 cases to local health departments in California. This guide provides step-by-step instructions to assist users in accurately completing the form online.

Follow the steps to fill out your CA CDPH 110d form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's name, including last name, first name, and middle initial in the designated fields.
3. Fill in the home address, ensuring to include the apartment or unit number if applicable, and provide the city and ZIP code.
4. Select the patient's ethnicity by checking the appropriate box, then indicate their race by checking all that apply.
5. Provide contact information, including home telephone number, cell number, and email address.
6. Enter the patient's age and birth date in the format (mm/dd/yyyy). Specify their current gender identity from the options provided.
7. Specify if the patient is pregnant and indicate if they have close contact with a laboratory-confirmed COVID-19 case.
8. Document the gender(s) of sex partners where applicable, as well as any additional contact details if necessary.
9. Complete the hospitalization status section, marking whether the individual has been hospitalized, intubated, and their current condition.
10. Indicate the results of COVID-19 tests and whether any respiratory complications or symptoms are present.
11. Report on chronic conditions and other relevant clinical information as prompted in the form.
12. Finally, review the entire form for accuracy and completeness. Save changes, download, and print or share the form as required.

Start filling out your CA CDPH 110d form online today to ensure timely reporting.