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CMR_DMV
Documents
Onset (mm/dd/yyyy) Date of First Specimen Collection (mm/dd/yyyy) Date of Diagnosis (mm/dd/yyyy) CONFIDENTIAL ... episode?: _______________ (mm/dd/yyyy) 2. If there have been multiple episodes of lossURL/globalassets/health/media-library/documents/diseases-and-condition/reporting-requirement/confidential-morbidity-reports/cdph110c_clb042011
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TB_CMR
Documents
Mantoux TB Skin Test Date Placed (mm/dd/yyyy) Date Read (mm/dd/yyyy) Results: _______ mm Not done Pending ... Collected: _______________ (mm/dd/yyyy) Specify test name: _____________________ Results:URL/globalassets/health/media-library/documents/diseases-and-condition/reporting-requirement/tb-laws-and-regulations/tb_cmr
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cmr-tb-reporting-2023
Document
Mantoux TB Skin Test Date Placed (mm/dd/yyyy) Date Read (mm/dd/yyyy) Results: _______ mm Not done Pending ... Collected: _______________ (mm/dd/yyyy) Specify test name: _____________________ Results:URL/globalassets/health/media-library/documents/services/clinics/tb/cmr-tb-reporting-2023
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CMR TB REPORTING 2023
Document
Mantoux TB Skin Test Date Placed (mm/dd/yyyy) Date Read (mm/dd/yyyy) Results: _______ mm Not done Pending ... Collected: _______________ (mm/dd/yyyy) Specify test name: _____________________ Results:URL/globalassets/health/media-library/documents/diseases-and-condition/reporting-requirement/tb-laws-and-regulations/cmr-tb-reporting-2023
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Adult Case Report Form
Documents
Name:Last Name:Alternate Name Type (e.g. Alias, Married, etc.): Address Type: Current Street Address: Phone ... Information (Record All Dates as mm/dd/yyyy) Date Form Completed: STATENO: CITYNO: ReportingURL/globalassets/health/media-library/documents/planning-and-research/reports/hiv-reports/adult-case-report-form
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Zika Test Request Form
Document
(Last, First, Middle Initial): Date of Birth (mm/dd/yyyy): Age: Sex: FEMALE Race/Ethnicity: □ White ... State, City): Dates of travel/residence (mm/dd/yyyy): From: To: Country of travel/residence (CountryURL/globalassets/health/media-library/documents/diseases-and-condition/resources-for-providers/guidelines-for-zika-virus/zika-test-request-form
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Fillable ACRF Long Beach
Document
Name:Last Name:Alternate Name Type (e.g. Alias, Married, etc.): Address Type: Current Street Address: Phone ... Facility Information (Record All Dates as mm/dd/yyyy) Date Form Completed: STATENO: CITYNO: ReportingURL/globalassets/health/media-library/documents/diseases-and-condition/reporting-requirement/hiv--aids/fillable-acrf-long-beach
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Fillable Adult Case Report Form Long Beach - Providers
Document
Name:Last Name:Alternate Name Type (e.g. Alias, Married, etc.): Address Type: Current Street Address: Phone ... Facility Information (Record All Dates as mm/dd/yyyy) Date Form Completed: STATENO: CITYNO: ReportingURL/globalassets/health/media-library/documents/diseases-and-condition/reporting-requirement/hiv--aids/fillable-adult-case-report-form-long-beach---providers
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Documents
DATE SPECIMEN TESTED* __________________ MM/ DD/YYYY FIRST NAME*: LAST NAME*: MIDDLE NAME: DATE ... DATE OF BIRTH*: __________________ MM/DD/YYYY PATIENTADDRESS GENDER*: Male Female Male-to-FemaleURL/globalassets/health/media-library/documents/diseases-and-condition/reporting-requirement/hiv--aids/standardhivlabreportform-june2015fillable
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LB_CMR-2022 (1)
Document
English Spanish Language Other: Birth Date (mm/dd/yyyy) Age Years Months Days Current Gender Identity ... Yes No Unknown Est. Delivery Date (mm/dd/yyyy) Country of Birth Occupation or Job Title OccupationalURL/globalassets/health/media-library/documents/diseases-and-condition/reporting-requirement/confidential-morbidity-reports/lb_cmr-2022--1-
