Get Ca Cdph 110d 2021-2025

This guide will provide you with clear, step-by-step instructions to help you fill out the CA CDPH 110d form online. This confidential morbidity report is specifically for reporting COVID-19 cases and must be submitted to the local health department within one working day.

Follow the steps to effectively complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the disease being reported. In this case, select COVID-19 from the options provided.
3. Enter the patient's name, including their last name, first name, and middle initial where applicable.
4. Provide the patient's home address, including city, state, ZIP code, and any apartment or unit number.
5. Indicate the ethnicity of the patient by checking the appropriate box for Hispanic/Latino or Non-Hispanic/Non-Latino.
6. Select the race of the patient by checking all that apply from the given options.
7. Complete the contact information, including home and cell phone numbers, and email address.
8. Specify the country of birth, birth date, age, and current gender identity of the patient.
9. Indicate the primary language spoken by the patient and their sexual orientation.
10. Provide the patient's hospitalization status, including any diagnostic test results, and tick relevant boxes for previous hospitalizations or intubation.
11. Complete the fields on underlying chronic conditions, vaccination history, and COVID-19 symptoms based on the patient's condition.
12. After filling in all required sections, save the form. You may choose to download, print, or share it as needed.

Complete your forms online to ensure timely reporting and compliance.