Epidemiologic Case History Forms
Forms are posted for information only. Except for certain conditions, non-public health healthcare providers are not expected to complete a questionnaire when reporting a condition.
CDC Quick Learn Lesson: Create an Epi Curve
Anaplasmosis
Babesiosis
Brucellosis
Candida auris
Carbapenem-resistant Enterobacteriaceae (CRE)
Chagas Disease
-
Chagas Disease Case History Form
(REDCap form for ACDC USE ONLY) - Chagas Disease Form for Non-Confirmed Cases (REDCap form for ACDC USE ONLY )
Chickenpox (Hospitalized Cases and Deaths)
- Varicella (Chickenpox) Hospitalized Case Report
- Varicella Death Investigation Worksheet
- Instructions (for the Varicella Death Investigation Worksheet)
Chickenpox (Varicella) Outbreaks
Chikungunya
Ciguatera Fish Poisoning
Coronavirus Disease 2019 (COVID-19)
- Provider and Laboratory Reporting Guidelines webpage
- Multisystem Inflammatory Syndrome in Children Associated with SARS-CoV-2 Infection Case Report Form
CRE (Carbapenem-resistant Enterobacteriaceae)
Creutzfeldt-Jakob Disease (CJD) and Transmissible Spongiform Encephalopathy (TSE)
Cronobacter Infection, Invasive (Infants: <12 months)
Cryptosporidiosis (outbreaks only)
Cyclosporiasis
Cysticercosis (Taeniasis)
Dengue (Break-Bone Fever)
Diphtheria
Domoic Acid (Amnesic Shellfish) Poisoning
Ehrlichiosis
Foodborne Disease Outbreak
Haemophilus Influenzae
Hansen's disease (Leprosy)
Hantavirus Infections
Hemolytic Uremic Syndrome (HUS)
Hepatitis B, Perinatal
-
Confidential HBsAg+ Case / Household Management Report
(PERINATAL HEPATITIS B PREVENTION UNIT USE ONLY)
Influenza, Novel (includes Avian)
Influenza (Human) Fatal
Legionellosis
Leprosy (Hansen's disease)
Leptospirosis
Listeriosis
- Listeriosis Case Report (ACDC USE ONLY)
- Neonatal Listeriosis Case Report (ACDC USE ONLY)
Lyme Disease
Malaria
Measles (Rubeola)
Meningococcal Infections
Middle East Respiratory Syndrome (MERS)
Monkeypox
- See Mpox Information for Health Providers webpage
Mumps
Myelitis, Acute Flaccid
Non-Tuberculous Mycobacterium, Extrapulmonary Form
Norovirus (outbreaks only)
Outbreaks - Coronavirus Disease 2019 (COVID-19)
Healthcare Facilities:
- Outbreak Investigation General Acute Care Hospital -
- Instructions
-
- Acute Psychiatric Hospitals
webpage
for details.
- Long-Term Healthcare Facilities (LTHFs)- SNFs, ICFs, CLHFs webpage for details.
(Outbreak forms are NOT required for COVID-19 LTHFs outbreaks.)
Community Settings:
-
See
webpage for details. (Outbreak forms are NOT required for COVID-19 Community outbreaks.)
Examples include:
- Education settings
- Community care facilities
- Sites serving people experiencing homelessness (PEH)
- Correctional/detention facilities
- Workplace settings
Outbreak - Foodborne Diseases
Outbreak - General or Non-Health Care Facility
Respiratory/Influenza:
- Acute Respiratory Illness Outbreak Report - Non-healthcare
- Influenza/Respiratory Outbreak Line List for Non-Healthcare Facilities-Students, Staff, Residents (PDF/Excel)
Outbreak - Health Care Facility (HF)
- Outbreak Investigation General Acute Care Hospital - Instructions (ACDC USE ONLY)
- CD Outbreak Investigation Sub-Acute Health Care Facility - Instructions
-
Sample Outbreak Line Lists:
-Gastrointestinal Illness/Norovirus-Patients/Residents & Staff (PDF/Excel)
-Influenza/Respiratory-Residents & Staff (PDF | Excel)
-Scabies-Patients & Employees (PDF/Excel)
Outbreak - Waterborne Diseases
Paralytic Shellfish Poisoning
Pertussis (Whooping Cough)
Plague
Pneumococcal, Invasive Disease
Poliomyelitis
Psittacosis
Q Fever
Rabies
Relapsing Fever
Respiratory Syncytial Virus (Fatal <5 years)
Rocky Mountain Spotted Fever
Rubella (German Measles,
Rubella Syndrome, Congenital
Scabies (atypical or crusted in a non-health facility)
Scombroid Fish Poisoning
Shiga Toxin-producing Escherichia coli (STEC)
-
Shiga Toxin-Producing Escherichia coli (STEC) and/or
Hemolytic Uremic Syndrome (HUS) Case Report
Additional Ill Contacts and Household Contacts are now contained within the STEC Case Report Form
Shigellosis
-
Shigellosis Case Report
Additional Ill Contacts and Household Contacts are now contained within the Shigellosis Case Report Form
Smallpox (Variola)
St. Louis Encephalitis Virus Infection
Streptococcal Group A,
Invasive
(Including Streptococcal Toxic Shock Syndrome and
Necrotizing Fasciitis)
Streptococcus pneumoniae, Invasive
Tetanus
- Tetanus Surveillance Worksheet
- Instructions (for the Tetanus Surveillance Worksheet)
Trichinosis
Tularemia (Rabbit Fever)
Typhoid Fever, Carrier
Typhus Fever and Other Non-Spotted Fever Rickettsioses
Vaccine Adverse Event Report (VAERS)
Varicella (Hospitalized Cases and Deaths)
- Varicella (Chickenpox) Hospitalized Case Report
- Instructions (for the Varicella Death Investigation Worksheet)