This CDC case report form collects surveillance data on spotted fever rickettsiosis (including Rocky Mountain spotted fever), anaplasmosis and ehrlichiosis. A clinician meets it when a patient is diagnosed with one of these infections and the state or local health department investigates. It follows the case from travel and tick bites through symptoms, complications, antibiotics and laboratory testing, and only confirmed and probable cases go on to CDC.
The health care provider or health department staff fill in the clinical, treatment and laboratory questions, and the provider's name appears at the top. The state health department official who reviewed the report adds their name, title and date along with the case outcome.
Download the current version from the source each time; forms change without notice.
Tickborne Rickettsial Disease Case 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.
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Spotted fever rickettsiosis, including Rocky Mountain spotted fever, Anaplasma phagocytophilum infection, Ehrlichia chaffeensis infection, Ehrlichia ewingii infection, and undetermined human ehrlichiosis or anaplasmosis. The form points to CDC's national notifiable disease case definitions for the complete criteria used to classify each case.
Name the performing laboratory, then enter up to two serology collection dates with IFA IgG and IgM results and titers, noting any fourfold IgG change. Other tests include PCR, morulae visualization, immunostain and culture confirmed by PCR, each with collection date and specimen type, plus the genus or species identified.