Instructions for filling out the CMR Form
- On first line of form, write the disease, and if applicable, the site of infection. Complete the patient's name, address, and date of birth, phone number, and gender. Social security numbers are not necessary. Enter the medical record number if applicable.
- Identify the whether the patient is pregnant, and if so, the estimated delivery date.
- On the far right, enter the patient's ethnicity and race, if known.
- On the center left, enter the date of onset and date of diagnosis. Enter the date of death if applicable.
- In the center of the form, complete the reporting healthcare provider section. Please include phone and fax numbers.
- The lower half of the page asks for additional information about sexually transmitted diseases, viral hepatitis, and tuberculosis.
- For hepatitis B or C, note whether the infection is chronic or acute.
- For syphilis, include signs and symptoms to support syphilis staging and doses and dates of treatment administered.
- If pertinent lab reports are available, please fax them along with the CMR.
- Please be as complete as possible when entering information. Fax or mail the completed report to the number or address shown on the center right.
- Fax numbers:
- All diseases except TB and HIV: 408-885-3709
- TB: 408-885-2331
Who is required to report a communicable diease?
- Medical doctors, osteopaths, veterinarians, podiatrists, nurse practitioners, physician assistants, nurses, nurse midwives, infection control practitioners, medical examiners, coroners, dentists, and administrators of health facilities and clinics (California Code of Regulations [CCR],Title 17, Section 2500).
- Anyone in charge of a public or private school, kindergarten, boarding school, or preschool (CCR, Title 17, Section 2508).
- Laboratories (CCR, Title 17, Section 2505).
Note that all three groups are required to report independent of one another. For example, if a provider knows that a lab has already reported a disease, the provider is still required to report the disease.