State of California—Health and Human Services Agency California Department of Public Health
CONFIDENTIAL MORBIDITY REPORT
FOR ANIMAL PATIENTS
DISEASE BEING REPORTED
OWNER OR RESPONSIBLE PARTY
Owner/Contact Name
Business/Agency Name
Address: Number, Street Apt./Unit No.
City State ZIP Code
Owner/Contact Telephone Number
Business/Agency Telephone Number
Business/Agency Fax Number
Email Address
ANIMAL PATIENT
Animal Name or Identification Code
Species Breed
Color
Sex
Male Female Unknow
Reproductive Status
Intact Neutered/Spayed Unknown
Age Ownership Status
Pet Stray Feral Livestock Wild, unowned Wild, captive Unknown
Address where Located or Recovered: Number, Street
City State ZIP Code
Date of Illness Onset (mm/dd/yyyy)
Date of First Specimen Collection (mm/dd/yyyy)
Date of Diagnosis (mm/dd/yyyy)
Date of Death (mm/dd/yyyy)
REPORTING AGENCY OR FACILITY
Reporting Individual Name
Occupation
Reporting Agency or Facility Name
Address: Number, Street Suite/Unit No.
City State ZIP Code
Telephone Number
Fax Number
Email Address
Submitted by
Date Submitted (mm/dd/yyyy)
LABORATORY
Laboratory Name
City State ZIP Code
Telephone Number
Fax Number
Remarks
REMARKS
REPORT TO:
(Obtain additional forms from your local health department.)
County of Santa Cruz
Communicable Disease Unit
1060 Emeline Ave., Bldg F
Santa Cruz, CA 95060
Phone: (831) 454-4114
Fax: (831) 454-5049
CDPH 8572 (10/11)
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