California providers use this report to notify the local health officer of a case or suspected case of a disease or condition reportable under Title 17, California Code of Regulations, section 2500. CDPH calls it the initial report required from the provider for any reportable disease, except HIV/AIDS, tuberculosis and conditions reportable to the DMV. Pages 3 to 5 reprint the Title 17 list with each condition's reporting deadline.
The health care provider who diagnoses or suspects the reportable condition completes the whole form; Title 17 defines providers to include physicians, nurse practitioners, physician assistants, registered nurses, dentists and others. There is no patient or employer section.
Name the disease or condition at the top of page 1; the fillable PDF offers it as a drop-down. The banner above it repeats the form's scope: use it for all conditions except HIV/AIDS, tuberculosis and conditions reportable to the DMV. Check the condition's urgency on the Title 17 list on page 3 before deciding whether a written report alone is enough.
Enter the patient's name, home address, home, cell and work phone numbers, email, primary language, birth date and age. The form also asks for gender identity, sex assigned at birth, sexual orientation, ethnicity and race, pregnancy status with estimated delivery date, country of birth, and occupation or job title. Check any occupational or exposure setting that applies: food service, day care, health care, correctional facility, school or other.
Record the date symptoms began, the date the first specimen was collected, the date of diagnosis and, if the patient died, the date of death, each as mm/dd/yyyy. The row sits between the occupation and exposure-setting fields and the reporting provider block on page 1.
Give the reporting health care provider and facility, address, telephone and fax numbers, who submitted the report and the date submitted. Name the laboratory with its city, state and ZIP code. The Report To box holds the local health department's details, and the form notes that additional forms can be obtained from the local health department.
For an STD, record the gender of sex partners and treatment: treated in office or given a prescription, drug, dosage and route, and start date, or why the patient is untreated. For syphilis, mark the stage, any neurologic, otic, ocular or late clinical manifestations, and results with titers for RPR, VDRL, FTA-ABS, TP-PA, EIA/CLIA and CSF-VDRL. For gonorrhea, check specimen sources and symptoms, then whether partners were treated.
The Remarks box at the bottom of page 1, below the STD section, is the only free-text field on the page, for details the structured fields do not capture. Outbreaks of any disease, including ones not on the section 2500 list, and any unusual disease are reportable immediately by telephone, not only in writing.
Page 2 repeats the patient's name and birth date. Check the diagnosis (hepatitis A, B, C, D or E, with acute, chronic or perinatal where listed), whether the patient is symptomatic, and suspected exposures such as transfusion or procedures, IV drug use, needle exposure, sexual, household or perinatal contact, or child care. Record ALT and AST with upper limits, bilirubin, and positive or negative serology from anti-HAV IgM through anti-HEV, plus HBV DNA.
These pages reprint section 2500, the urgency codes and the full list. A telephone symbol with an exclamation mark means report immediately by phone; a telephone alone means by phone within one working day; FAX, phone and mail symbols mean any of those within one working day; WEEK means within seven calendar days. Page 5 also covers HIV reporting, noncommunicable conditions such as pesticide-related illness and cancer, and a box for locally reportable diseases.
Download the current version from the source each time; forms change without notice.
Confidential Morbidity Report
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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HIV/AIDS, tuberculosis and conditions reportable to the DMV. Tuberculosis goes on CDPH 110b, and CDPH 110c covers lapses of consciousness or control, Alzheimer's disease and other conditions that may impair safe driving. COVID-19 has its own form, CDPH 110d, and conditions in animal patients use CDPH 8572.
It depends on the condition's symbol on the Title 17 list. Some must be reported immediately by telephone, such as anthrax and measles. Others are reported by phone within one working day, or by fax, phone or mail within one working day. All other listed conditions are due within seven calendar days of identification.
Under Title 17 section 2500(b), every health care provider who knows of or attends a case or suspected case of a listed disease must report it to the local health officer where the patient resides. Section 2500(c) makes health facility and clinic administrators responsible for procedures that ensure reports are made.
Yes, where the local health department uses it, the report can be entered in the CalREDIE Provider Portal instead of faxing or mailing the PDF. CalREDIE is replacing paper reporting in many local health departments, and some large counties, such as Los Angeles, publish their own CMR version.