Form 0920-15CN Attachment G_Viral Hemorrhagic Fever Case Investigation

OMB Approved
0920-XXXX
Expiration Date

LIBERIA EBOLA CASE INVESTIGATION FORM

Outbreak
Case ID:

Date of Case Report: ____/____/_____ (DD, MM, YY)

Section 1.

Patient Information

Patient’s Last Name: ______________________ First Name:__________________________
Age: ______
Years
Months
Gender:
Male
Female
Mobile Phone Number: __________________________
Patient Status at Time of This Report:

Alive

Dead If dead, Date of Death: ___/___/___ (DD, MM, YY)

Permanent Residence:
Head of Household: _____________________ Village/Town: ____________________ Zone: ________________
Country of Residence: __________________ County: _____________________ District: ___________________
Occupation:
Healthcare worker; position: ____________________ healthcare facility: ______________________
Other; please specify occupation: ________________________
Location Where Patient Became Ill:
Village/Town: ______________________ County: ______________________ District: _____________________

Section 2.
Date Patient First Became Sick:

Clinical Signs and Symptoms
____/____/______ (D, M, Yr)

Please mark an answer for ALL symptoms indicating if they occurred during this illness:
Fever
Vomiting/nausea
Diarrhea
Intense fatigue/weakness
Anorexia/loss of appetite
Abdominal pain
Muscle pain
Joint pain

Section 3.

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No

Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk

Headache
Difficulty breathing
Difficulty swallowing
Hiccups

Yes
Yes
Yes
Yes

No
No
No
No

Unk
Unk
Unk
Unk

Unexplained bleeding
Yes
No
Unk
If yes, please specify: ________________________

Hospitalization Information

At the time of this case report, is the patient hospitalized or being admitted to the hospital?

Yes

No

If yes, Date of Hospital Admission: ____/____/_____ (DD, MM, YY)
Hospital Name: ____________________________ County: _____________________
Is the patient now, or will he/she soon be, in an Ebola treatment unit (ETU)?

Yes

No

If yes, date of admission (or future admission) to the ETU (isolation): ____/____/_____ (DD, MM, YY)
Was the patient hospitalized or did he/she visit a clinic previously for this illness?

Yes

No

Unk

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor,
and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton
Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX.

OMB Approved
0920-XXXX
Expiration Date

If yes, Dates of Hospitalization: ___/___/____ - ___/___/____(DD, MM, YY)
Hospital/Clinic Name:: __________________ County: _________________

Section 4.

Epidemiological Risk Factors and Exposures

IN THE PAST ONE(1) MONTH PRIOR TO SYMPTOM ONSET:
1. Did the patient have contact with an Ebola case or any sick person in the one month before becoming

ill?

Yes

No

Unk

If yes, please complete one line of information for each sick source case:
Name of Source Case

Date of Last
Contact

Village

County

Was the person dead or alive ?

(DD, MM, YY)

___/___/___

Alive
Dead, date of death: ___/___/___ (DD, MM, YY)

___/___/___

Alive
Dead, date of death: ___/___/___ (DD, MM, YY)

2. Did the patient attend a funeral in the one month before becoming ill?

Yes

No

Unk

If yes, Name of Deceased Person: ___________________ Date of Funeral: (DD, MM, YY): ___/___/____
Village/Town: ___________________________ County: ___________________________
Did the patient participate (carry or touch the body)?

Yes

No

3. Did the patient travel outside their home or village/town before becoming ill?
Yes
No
Unk
If yes, Village: ________________ County: ________________ Date(s): ___/___/___ - ___/___/___ (DD, MM, YY)

Section 6.

Case Report Form Completed by:

Name: __________________________ Phone: ______________________ E-mail: ________________________

Section 7.

Patient Outcome Information

Please fill out this section at the time of patient recovery and discharge from the hospital
OR at the time of patient death.
Date Outcome Information Completed: ____/____/_____ (DD, MM, YY)
Final Status of the Patient:

Alive/Recovered

Dead

If the patient has recovered and been discharged from the hospital:
Hospital discharged from: ____________________County: __________________
Date of discharge from the hospital: ____/____/______ (DD, MM, YY)
If the patient was isolated in an Ebola treatment unit, Date of discharge from isolation: ____/____/____ (DD, MM, YY)
Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor,
and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton
Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX.

OMB Approved
0920-XXXX
Expiration Date

If the patient is dead:
Date of Death: ____/____/_____ (DD, MM, YY) Place of Death:

Community

Date of Funeral/Burial: ___/___/___ (DD, MM, YY) Funeral conducted by:

LABORATORY FORM (sample #2)

Hospital: __________________

Family/community

Outbreak burial team

Outbreak
Case ID:

Patient’s Last Name: ______________________ First Name:____________________________
Age: _______

Years

Months

Gender:

Male

Female

Permanent Residence:
Village/Town: _____________________ County: _____________________ Country of Residence: _________________
Date of Initial Symptom Onset:

____/____/______ (DD, MM, YY)

Patient Status at Time Sample Collected:

Alive

Dead

If dead, Date of Death: ___/___/____ (DD, MM, YY)

Health Facility Submitting Sample: _____________________ Person Submitting Sample: ____________________
Submitter’s Phone Number: ________________________ Submitter’s Email: _______________________________
Has this patient had a sample submitted previously?

Yes

No

Sample 1:

Sample 2:

Sample Collection Date: ____/____/______ (DD, MM, YY)

Sample Collection Date: ____/____/____ (DD, MM, YY)

Sample Type:
Whole Blood
Post-mortem heart blood
Skin biopsy
Saliva swab
Other specimen type, specify: ________________

Sample Type:
Whole Blood
Post-mortem heart blood
Skin biopsy
Saliva swab
Other specimen type, specify: ___________

LABORATORY FORM (sample #1)

Outbreak
Case ID:

Patient’s Last Name: ______________________ First Name:____________________________
Age: _______
Years
Months
Gender:
Male
Female
Permanent Residence:
Village/Town: _____________________ County: _____________________ Country of Residence: _________________
Date of Initial Symptom Onset:

____/____/______ (DD, MM, YY)

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor,
and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton
Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX.

OMB Approved
0920-XXXX
Expiration Date

Patient Status at Time Sample Collected:

Alive

Dead

If dead, Date of Death: ___/___/____ (DD, MM, YY)

Health Facility Submitting Sample: _____________________ Person Submitting Sample: ____________________
Submitter’s Phone Number: ________________________ Submitter’s Email: _______________________________
Has this patient had a sample submitted previously?

Yes

No

Sample 1:

Sample 2:

Sample Collection Date: ____/____/______ (DD, MM, YY)

Sample Collection Date: ____/____/____ (DD, MM, YY)

Sample Type:
Whole Blood
Post-mortem heart blood
Skin biopsy
Saliva swab
Other specimen type, specify: ________________

Sample Type:
Whole Blood
Post-mortem heart blood
Skin biopsy
Saliva swab
Other specimen type, specify: __________

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor,
and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton
Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX.