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State of CaliforniaHealth and Human Services Agency California Department of Public HealthPERTUSSIS SUPPLEMENTAL FORM
for cases 4 months of age
Contact Mother of Infant Pertussis Case to complete
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How to fill out pertussis supplemental form
How to fill out pertussis supplemental form
01
To fill out the pertussis supplemental form, follow these steps:
1. Obtain a copy of the form from your healthcare provider or download it from their website.
2. Read the instructions provided on the form carefully to understand the information required.
3. Gather all relevant information, such as personal details, immunization history, and any known exposure to pertussis.
4. Begin filling out the form by providing your name, contact information, and demographic details as requested.
5. Enter your immunization history, including dates of pertussis vaccinations, if any.
6. Indicate any known exposure to pertussis by providing the necessary details, such as the source of exposure and the dates.
7. Double-check all the entered information for accuracy and completeness.
8. Sign and date the form.
9. Submit the filled-out form to your healthcare provider as instructed.
Who needs pertussis supplemental form?
01
The pertussis supplemental form may be required for individuals who:
1. Have been exposed to pertussis or are suspected to have pertussis.
2. Require documentation of their pertussis vaccination history.
3. Need to report a case of pertussis to health authorities.
4. Are participating in medical research or clinical trials related to pertussis.
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What is pertussis supplemental form?
The pertussis supplemental form is a document used to report additional information related to pertussis cases.
Who is required to file pertussis supplemental form?
Healthcare providers and medical facilities are required to file the pertussis supplemental form.
How to fill out pertussis supplemental form?
The pertussis supplemental form can be filled out online or submitted in person with the required information about the pertussis case.
What is the purpose of pertussis supplemental form?
The purpose of the pertussis supplemental form is to collect detailed information on pertussis cases for public health monitoring and research purposes.
What information must be reported on pertussis supplemental form?
Information such as demographics of the patient, symptoms, treatment, and potential sources of exposure must be reported on the pertussis supplemental form.
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