The California PM110 form is a Confidential Morbidity Report used by health care providers to report certain communicable diseases, including STDs, hepatitis, and tuberculosis. This form ensures that health authorities can monitor and manage public health effectively. If you need to complete the PM110 form, please click the button below.
The California PM110 form is a crucial document designed to facilitate the reporting of specific communicable diseases and conditions by healthcare providers in the state. This form serves as a confidential morbidity report, allowing for the systematic tracking of diseases such as sexually transmitted infections, hepatitis, and tuberculosis. It includes essential patient information, including demographics, disease specifics, and treatment details. Healthcare providers must fill out various sections of the form depending on the disease being reported, ensuring that all relevant data is accurately captured. The PM110 form also outlines special reporting requirements, emphasizing the importance of timely notifications to local health authorities. By adhering to these guidelines, healthcare providers play a vital role in safeguarding public health and preventing the spread of communicable diseases in California.
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 vital step in reporting specific health conditions. This form must be filled out accurately to ensure that the necessary health authorities receive the information they need. Below are the steps to guide you through the process of filling out the PM110 form effectively.
After completing the form, ensure that all information is accurate and legible. Once submitted, the local health department will process the report. This is an important step in maintaining public health and safety.
The California PM110 form is a Confidential Morbidity Report used by healthcare providers to report specific diseases to local health authorities. This form is essential for tracking communicable diseases such as sexually transmitted diseases, hepatitis, and tuberculosis. Accurate reporting helps public health officials monitor outbreaks and implement necessary interventions.
Healthcare providers, including physicians, nurses, and other licensed professionals, are required to complete the PM110 form when they are aware of a case or suspected case of reportable diseases. If no healthcare provider is present, any individual with knowledge of the situation may report it. This ensures that all cases are documented and addressed appropriately.
The form requires detailed patient information, including:
Completing all sections accurately is crucial for effective disease monitoring.
The PM110 form can be submitted via electronic transmission, fax, or mail. It is important to follow the submission guidelines outlined in the California Code of Regulations to ensure timely reporting. Depending on the urgency of the case, different submission methods may be required.
Failure to report cases on the PM110 form is considered a misdemeanor and can lead to civil penalties. Healthcare providers may face fines or other disciplinary actions for non-compliance. Reporting is not just a legal obligation; it plays a vital role in protecting public health.
Yes, the California regulations specify deadlines based on the type of disease being reported. Urgent cases may need to be reported immediately, while others must be reported within one to seven days. Adhering to these timelines is essential for effective public health responses.
No, the PM110 form is specifically designed for reporting certain communicable diseases as outlined in California regulations. For other types of illnesses or conditions, different forms or reporting mechanisms may be necessary. Always refer to the latest guidelines to determine the correct procedures.
Additional copies of the PM110 form can be obtained from your local health department. They can provide you with the most current version of the form and any additional resources you may need for reporting.
Incomplete Patient Information: Failing to provide all necessary details about the patient can lead to delays in processing. Essential information includes the patient’s full name, date of birth, and social security number. Omitting any of these details may result in the form being returned or not processed correctly.
Incorrect Disease Reporting: Selecting the wrong disease from the list can have serious implications. It is crucial to ensure that the disease being reported matches the symptoms and diagnosis. Misreporting can lead to public health risks and legal consequences.
Neglecting to Sign the Form: The form must be signed by the reporting healthcare provider. A missing signature can invalidate the report, causing unnecessary complications in the reporting process.
Failing to Meet Deadlines: Timeliness is critical in reporting communicable diseases. Not adhering to the required reporting timelines can result in penalties. It is essential to be aware of the specific deadlines for different diseases and conditions.
Ignoring Confidentiality Requirements: The information on the PM110 form is confidential. Failing to handle the form securely can lead to breaches of privacy laws. Always ensure that the form is submitted and stored in a manner that protects patient confidentiality.
The California PM110 form serves as a vital tool for reporting various communicable diseases and conditions to local health authorities. In addition to this form, there are several other documents that healthcare providers often utilize to ensure comprehensive reporting and compliance with public health regulations. Below is a brief overview of five such forms and documents commonly used alongside the PM110.
These forms, when used in conjunction with the California PM110, contribute to a more robust public health reporting system. They enable healthcare providers to communicate effectively with health authorities, ultimately supporting efforts to monitor and control diseases within the community.
The California PM110 form is similar to the CDC's National Notifiable Diseases Surveillance System (NNDSS) form. Both documents serve the purpose of reporting communicable diseases to health authorities. The NNDSS form collects information on various diseases that are deemed significant to public health, similar to the PM110's focus on STDs, hepatitis, and tuberculosis. Both forms require detailed patient information, including demographics and clinical data, to ensure accurate tracking and management of public health concerns.
Another document comparable to the PM110 is the HIV/AIDS Case Report form (CDPH 8641A). Like the PM110, this form is used by healthcare providers to report specific diseases that have public health implications. The HIV/AIDS form emphasizes the importance of timely reporting, requiring submissions within seven days of diagnosis. Both forms aim to facilitate disease surveillance and control, ensuring that health authorities can respond effectively to outbreaks and trends in disease transmission.
The Confidential Physician Cancer Reporting Form also shares similarities with the PM110. This form is utilized by healthcare providers to report cancer cases, highlighting the need for accurate and timely data collection for public health monitoring. Both forms require patient identification and clinical details, enabling health departments to analyze trends and implement necessary interventions. Each form emphasizes the legal obligation of healthcare providers to report specific health conditions to protect community health.
Lastly, the Birth and Death Certificate forms are similar in that they are essential for public health tracking and demographic analysis. While the PM110 focuses on communicable diseases, birth and death certificates provide critical information on population health and mortality trends. Both types of documents are vital for understanding public health issues and guiding health policy decisions. They require accurate information to ensure the integrity of health data used for planning and resource allocation.
When filling out the California PM110 form, it is essential to ensure accuracy and compliance with reporting requirements. Below are some key dos and don’ts to guide you through the process.
Misconception 1: The PM110 form is only for reporting sexually transmitted diseases (STDs).
This form is actually designed for reporting a variety of communicable diseases, not just STDs. It includes sections for viral hepatitis, tuberculosis, and other reportable diseases as outlined by California regulations.
Misconception 2: Only doctors can fill out the PM110 form.
While healthcare providers are primarily responsible for completing this form, any individual who knows of a suspected case can report it. This means that nurses, administrators, and even members of the public can submit a report if necessary.
Misconception 3: The PM110 form must be submitted immediately for all diseases.
Reporting timeframes vary depending on the disease. Some require immediate reporting, while others can be reported within a specific number of days. Understanding these timelines is essential for compliance.
Misconception 4: Once submitted, the information on the PM110 form is publicly accessible.
The PM110 form is confidential. Information submitted is protected and used only for public health purposes. Privacy is a priority in handling these reports.
Here are some key takeaways about filling out and using the California PM110 form: