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Blank California Pm110 PDF Form

The California PM110 form is a Confidential Morbidity Report used by healthcare providers to report certain communicable diseases, including sexually transmitted diseases, hepatitis, and tuberculosis. This form is essential for ensuring public health and safety, as it allows local health authorities to track and manage disease outbreaks effectively. To fill out the PM110 form, please click the button below.

Article Guide

The California PM110 form serves as a crucial tool for healthcare providers in reporting various communicable diseases and conditions that pose a public health risk. Designed by the California Department of Public Health, this form is not just a bureaucratic requirement; it plays a vital role in tracking diseases such as sexually transmitted infections, hepatitis, and tuberculosis. When completing the PM110, healthcare providers must include essential patient information, including demographics, disease specifics, and treatment details. The form also outlines specific reporting requirements, emphasizing the urgency of notifying local health authorities about certain diseases. Failure to report can lead to significant legal consequences, underscoring the importance of compliance. Additionally, the PM110 includes sections dedicated to sexually transmitted diseases and tuberculosis, ensuring that healthcare providers can provide detailed information relevant to these conditions. By understanding the PM110 form and its requirements, healthcare professionals can contribute effectively to public health efforts and help contain outbreaks before they escalate.

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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?

Month

Day

Year

❒ Hawaiian

–

Unk

❒ Other:________________________

❒ Native American/Alaskan Native

Area Code

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

Month

Day

Year

Reporting Health Care Facility

DATE DIAGNOSED

Address

Month

Day

Year

City

State

ZIP Code

DATE OF DEATH

Telephone Number

Fax

Month

Day

Year

(

)

(

)

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

Titer:__________

❒ Hep B

HBsAg

❒

❒ Early latent < 1 year

❒Congenital

❒ FTA/MHA:

❒ Pos

❒ Neg

❒ Acute

anti-HBc

❒

❒ Latent (unknown duration)

❒ CSF-VDRL:

❒ Pos

❒ Neg

❒ Chronic

anti-HBc IgM

❒

❒ Neurosyphilis

❒ Other:_________________

anti-HBs

❒

Gonorrhea

Chlamydia

❒ PID (Unknown Etiology)

❒ Hep C

anti-HCV

❒

❒ Urethral/Cervical

❒ Acute

❒ Chancroid

PCR-HCV

❒

❒ PID

❒ Chronic

❒ 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

____________________________

Month

Day

Year

❒ 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

Year

Month Day

Year

❒ INH

❒ RIF

❒ PZA

❒ Confirmed

❒ EMB

❒ Other:____________

❒ Suspected

Date Performed

Date Specimen Collected

Month

Day

Year

❒ Infected, No Disease

❒ Pending

Date Treatment

❒ Convertor

Results:______________ mm ❒ Not Done

Source _______________________________________

Initiated

❒ Reactor

Smear:

❒Pos

❒Neg

❒Pending

❒Not done

Chest X-Ray Month

Day

Year

Culture:

❒Pos

❒Neg

❒Pending

❒Not done

❒ Untreated

Site(s)

❒ Will treat

❒ Pulmonary

Date Performed

Other test(s) ___________________________________

❒ Unable to contact patient

❒ Extra-Pulmonary

❒Normal

❒Pending ❒Not done

❒ Refused treatment

❒Both

❒Cavitary

❒Abnormal/Noncavitary

_______________________________________

❒ Referred to:_____________________

REMARKS

PM 110 (revised 12/08/09)

page 1 of 2

➤ PDF File

Form Specifications

Fact Name	Details
Purpose	The California PM110 form is used for reporting certain communicable diseases, including sexually transmitted diseases, viral hepatitis, and tuberculosis, to local health authorities.
Governing Laws	This form is governed by Title 17 of the California Code of Regulations, specifically sections 2500, 2593, and 2641.5-2643.20, which outline reporting requirements for health care providers.
Confidentiality	Information submitted on the PM110 form is confidential and is intended for use by health authorities to monitor and control the spread of diseases.
Reporting Timeline	Health care providers must report cases of specified diseases within certain timeframes, such as within one working day for urgent cases, as outlined in section 2500 of the regulations.
Consequences of Non-Compliance	Failure to report as mandated can lead to misdemeanor charges and civil penalties, emphasizing the importance of timely and accurate reporting.

California Pm110: Usage Guidelines

After gathering all necessary information, you can proceed to fill out the California PM110 form. Ensure that you have accurate details about the patient and the disease being reported. Follow the steps below to complete the form correctly.

Identify the disease being reported: Write the name of the disease in the designated space at the top of the form.
Fill in patient information: Enter the patient's last name, first name, middle name or initial, and social security number.
Complete demographic details: Mark the appropriate boxes for ethnicity and race, and provide the patient's birth date and age.
Enter the patient's address: Include the street address, apartment/unit number, city, state, and ZIP code.
Provide contact information: Fill in the area code and phone numbers for both home and work.
Indicate gender and pregnancy status: Mark the appropriate boxes for gender and whether the patient is pregnant.
Document delivery date: If applicable, enter the estimated delivery date.
Record the date of onset: Enter the month, day, and year when the symptoms began.
Provide reporting details: Fill in the name of the reporting health care provider and facility, along with their addresses and contact numbers.
Enter diagnosis dates: Record the date diagnosed, date of death (if applicable), and the date the report is submitted.
Complete the STD, Hepatitis, or TB sections: Fill in the relevant information based on the type of disease being reported.
Provide treatment information: Indicate whether the patient has been treated and provide details about the treatment.
Include remarks: Use the remarks section for any additional information that may be relevant to the report.

Your Questions, Answered

What is the California PM110 form?

The California PM110 form is a confidential morbidity report used by healthcare providers to report certain communicable diseases to the local health department. This form is essential for tracking and managing public health concerns, including sexually transmitted diseases (STDs), viral hepatitis, and tuberculosis (TB). It ensures that health authorities can monitor disease outbreaks and implement necessary interventions.

Who is required to complete the PM110 form?

Any healthcare provider who is aware of or attending to a case of a reportable disease must complete the PM110 form. This includes physicians, nurse practitioners, and other medical professionals. If no healthcare provider is present, any individual who knows about a suspected case can report it. This broad requirement helps ensure that all cases are documented and reported promptly.

What types of diseases must be reported using the PM110 form?

The PM110 form is specifically designed for reporting various communicable diseases, including but not limited to STDs like syphilis and chlamydia, viral hepatitis types A, B, and C, and tuberculosis. A complete list of reportable diseases is provided on the back of the form and includes many other conditions that pose a risk to public health.

How quickly must a report be submitted?

Reporting timelines vary depending on the disease. Some diseases must be reported immediately by phone, while others can be reported within one working day or seven calendar days after identification. The urgency of the report depends on the disease's potential impact on public health and safety.

What information is required on the PM110 form?

The form collects essential information about the patient, including their name, date of birth, ethnicity, and address. Additionally, it requires details about the disease being reported, the healthcare provider’s information, and any relevant test results. This comprehensive data helps health officials understand the scope of the issue and respond accordingly.

What happens if a healthcare provider fails to report a case?

Failure to report a case using the PM110 form is considered a misdemeanor and can result in penalties. Healthcare providers may face fines or other legal consequences for not complying with reporting requirements. This emphasizes the importance of timely and accurate reporting to protect public health.

Where can I obtain more PM110 forms?

Healthcare providers can obtain additional copies of the PM110 form from their local health department. It is also available online through the California Department of Public Health’s website. Ensuring that the correct forms are readily available helps facilitate the reporting process and supports public health initiatives.

Common mistakes

Incomplete Patient Information: Failing to provide all necessary details such as the patient's last name, date of birth, and social security number can lead to processing delays. Each piece of information is crucial for accurate identification.
Incorrect Disease Identification: Misreporting the disease being reported or selecting the wrong category can result in confusion and mismanagement of public health responses. It's essential to ensure the correct disease is marked clearly.
Missing or Incorrect Dates: Omitting important dates, such as the date of onset or date diagnosed, can hinder the investigation process. All dates must be filled in accurately to ensure proper tracking and follow-up.
Failure to Indicate Treatment Status: Not specifying whether the patient has been treated or is untreated can lead to miscommunication regarding the urgency of the case. Treatment status should be clearly indicated to inform health authorities.
Inaccurate Contact Information: Providing incorrect or outdated contact information for the reporting health care provider can create obstacles in communication. Always double-check that the phone numbers and addresses are accurate.
Neglecting to Report Urgent Cases: Some diseases require immediate reporting. Failing to recognize and report these cases promptly can jeopardize public health. Be aware of the urgency requirements for specific diseases.
Overlooking Special Reporting Requirements: Certain diseases have specific reporting guidelines. Ignoring these can lead to incomplete reports. Familiarize yourself with any special requirements associated with the disease being reported.
Not Keeping a Copy of the Submitted Form: Failing to retain a copy of the submitted PM110 form can cause issues if follow-up is needed. Always keep a record for your files to ensure you have documentation of what was reported.

Documents used along the form

The California PM110 form is a crucial document for reporting certain communicable diseases. When dealing with public health, various other forms and documents often accompany the PM110 to ensure comprehensive reporting and management of health concerns. Here’s a list of some of these important documents:

CDPH 8641A (HIV/AIDS Case Report Form): This form is specifically for reporting cases of Human Immunodeficiency Virus (HIV). Health care providers must submit it within seven days of diagnosis.
Confidential Physician Cancer Reporting Form: Used for reporting cancer cases, this form helps track cancer incidence and treatment in California.
TB Case Report Form: This document is used to report tuberculosis cases, providing detailed information on diagnosis, treatment, and patient history.
Viral Hepatitis Case Report Form: This form captures information on patients diagnosed with viral hepatitis, including type and treatment history.
STD Case Report Form: Health care providers use this form to report sexually transmitted diseases, ensuring proper tracking and management of cases.
Foodborne Illness Report Form: This form is essential for reporting suspected foodborne illnesses, helping health officials investigate outbreaks.
Invasive Disease Report Form: This document is for reporting cases of invasive diseases, which can help in identifying outbreaks and trends in public health.
Pesticide-Related Illness Report Form: Used to report illnesses or injuries related to pesticide exposure, this form is crucial for monitoring public health risks.
General Communicable Disease Report Form: This form allows for the reporting of various communicable diseases not covered by specific forms, ensuring comprehensive data collection.

Using these forms in conjunction with the PM110 helps health authorities maintain accurate records and respond effectively to public health issues. Each document serves a specific purpose, contributing to a broader understanding of health trends and risks in California.

Similar forms

The California PM110 form is designed for the reporting of communicable diseases and conditions. It shares similarities with several other documents used in public health reporting. Below are four documents that are comparable to the PM110 form:

CDC Case Report Form: This form is utilized nationally to report cases of infectious diseases. Like the PM110, it collects patient demographics, disease specifics, and treatment information, ensuring standardized reporting across jurisdictions.
HIV/AIDS Case Report Form (CDPH 8641A): This form is specifically for reporting HIV infections. Similar to the PM110, it requires detailed patient information and is mandated by health regulations, emphasizing the importance of timely reporting for public health surveillance.
Confidential Physician Cancer Reporting Form: This document is used for reporting cancer cases in California. It parallels the PM110 in that it gathers critical patient data and disease specifics, aiding in the monitoring of cancer trends and outcomes.
Reportable Noncommunicable Diseases Form: This form addresses noncommunicable diseases such as certain cancers and pesticide-related illnesses. Like the PM110, it is essential for tracking public health issues, ensuring that health authorities can respond effectively to emerging health threats.

Dos and Don'ts

When filling out the California PM110 form, it's important to follow specific guidelines to ensure accuracy and compliance. Here’s a list of things to do and avoid:

Do provide accurate patient information, including full names and correct birth dates.
Do check all applicable boxes for ethnicity and race to ensure proper classification.
Do include the patient's social security number, if available, as it helps with identification.
Do clearly indicate the disease being reported in the designated section.
Do ensure that the reporting health care provider's information is complete and accurate.

Don't leave any required fields blank, as incomplete forms may delay processing.
Don't use abbreviations or shorthand that may confuse the reader.
Don't provide false information, as this can lead to legal consequences.
Don't forget to submit the form within the required time frame to comply with reporting regulations.

Misconceptions

Misconception 1: The PM110 form is only for sexually transmitted diseases (STDs).

This form is actually used for reporting various communicable diseases, including tuberculosis and hepatitis, not just STDs.

Misconception 2: Only doctors can fill out the PM110 form.

Any health care provider, including nurses and physician assistants, can complete this form if they are aware of a reportable disease.

Misconception 3: The information on the PM110 form is not confidential.

In fact, the PM110 form is designed to maintain patient confidentiality while reporting necessary health information.

Misconception 4: Reporting is optional for health care providers.

Reporting is mandatory for health care providers who know of a case or suspected case of a reportable disease.

Misconception 5: The PM110 form is only for cases that have been diagnosed.

Providers should report suspected cases as well, not just confirmed diagnoses.

Misconception 6: There are no deadlines for submitting the PM110 form.

There are specific time frames for reporting different diseases, which providers must follow to ensure timely public health responses.

Misconception 7: The PM110 form can be submitted by anyone who knows about a disease.

Only health care providers or individuals with knowledge of a case can submit the form to the local health officer.

Key takeaways

When filling out and using the California PM110 form, keep these key takeaways in mind:

Confidentiality is crucial. This form is designed to report sensitive health information. Ensure that patient details are kept confidential and shared only with authorized personnel.
Accuracy is essential. Double-check all entries, including names, dates, and disease specifics. Incorrect information can lead to delays in treatment and public health responses.
Timeliness matters. Reports must be submitted promptly. Depending on the disease, some cases require immediate reporting, while others may have a seven-day window.
Follow specific reporting requirements. Different diseases have unique reporting protocols. Familiarize yourself with these to ensure compliance with California's health regulations.
Consult local health authorities. If you have questions or need additional forms, reach out to your local health department. They can provide guidance and support in completing the PM110 form.