2014016-XXX_Ebola_DRC

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Appendix 1
CASE REPORT FORM

Public reporting burden of this collection of information is estimated to average 25 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 (0920-1011)

VIRAL HEMORHAGIC FEVER
CASE INVESTIGATION FORM

Outbreak
Case ID:
Health
Facility
Case ID:

Date of Case Report: ____/____/_____ (D, M, Yr)

Section 1.

Patient Information

Patient’s Surname: ______________________ Other Names:____________________________
Age: _______
Years
Months
Gender:
Male
Female
Phone Number of Patient/Family Member:_____________________ Owner of Phone: ________________
Status of Patient at Time of This Case Report:

Alive

Dead

If dead, Date of Death: ___/___/____ (D, M, Yr)

Permanent Residence:
Head of Household: __________________________ Village/Town: _______________________ Parish: __________________________
Country of Residence: _________________ District: ____________________________ Sub-County: ____________________________
Occupation:
Farmer
Butcher
Hunter/trader of game meat
Miner
Religious leader
Housewife
Pupil/student
Child
Businessman/woman; type of business: _____________________
Transporter; type of transport: ___________________________
Healthcare worker; position: _________________ healthcare facility: ___________________
Traditional/spiritual healer
Other; please specify occupation: _____________________________________________________
Location Where Patient Became Ill:
Village/Town: _________________________ District: _________________________ Sub-County: _________________________
GPS Coordinates at House: latitude: __________________ longitude: ________________________
If different from permanent residence, Dates residing at this location: ___/___/____ - ___/___/____ (D, M, Yr)

Section 2.

Clinical Signs and Symptoms

Date of Initial Symptom Onset:

____/____/______ (D, M, Yr)

Please tick an answer for ALL symptoms indicating if they occurred during this illness between symptom onset and case detection:

Fever
If yes, Temp: ____º C Source:

Yes
Axillary

Vomiting/nausea
Diarrhea
Intense fatigue/general weakness
Anorexia/loss of appetite
Abdominal pain
Chest pain
Muscle pain
Joint pain
Headache
Cough
Difficulty breathing
Difficulty swallowing
Sore throat
Jaundice (yellow eyes/gums/skin)
Conjunctivitis (red eyes)
Skin rash
Hiccups
Pain behind eyes/sensitive to light
Coma/unconscious
Confused or disoriented

Section 3.

Oral

No

Unk

Rectal

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk

Unexplained bleeding from any site
If Yes:
Bleeding of the gums
Bleeding from injection site
Nose bleed (epistaxis)
Bloody or black stools (melena)
Fresh/red blood in vomit (hematemesis)
Digested blood/“coffee grounds” in vomit
Coughing up blood (hemoptysis)
Bleeding from vagina,
other than menstruation
Bruising of the skin
(petechiae/ecchymosis)
Blood in urine (hematuria)

Yes

No

Unk

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No

Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk

Yes

No

Unk

Yes

No

Unk

Other hemorrhagic symptoms
Yes
No
Unk
If yes, please specify: ___________________________
Other non-hemorrhagic clinical symptoms:
Yes
No
If yes, please specifiy: ___________________________

Unk

Hospitalization Information

At the time of this case report, is the patient hospitalized or currently being admitted to the hospital?
If yes, Date of Hospital Admission: ____/____/_____ (D, M, Yr)

Yes

No

Health Facility Name: ________________________________________

Village/Town: __________________________ District: _______________________ Sub-County: _________________________
Is the patient in isolation or currently being placed there?
Yes
No
If yes, date of isolation: ____/____/_____ (D, M, Yr)
Was the patient hospitalized or did he/she visit a health clinic previously for this illness?

Yes

No

Unk

If yes, please complete a line of information for each previous hospitalization:
Dates of Hospitalization

Health Facility Name

Village

District

Was the patient isolated?

___/___/____ - ___/___/____ (D, M, Yr)

Yes
No

___/___/____ - ___/___/____ (D, M, Yr)

Yes
No

Outbreak
Case ID:

Section 4.

Epidemiological Risk Factors and Exposures

IN THE PAST ONE(1) MONTH PRIOR TO SYMPTOM ONSET:
1. Did the patient have contact with a known or suspect case, or with any sick person before becoming ill?
If yes, please complete one line of information for each sick source case:
Name of Source
Case

Relation to
Patient

Dates of Exposure

Village

District

No

Was the person dead or alive ?

Unk
Contact
Types**

(D, M, Yr)
Alive
Dead, date of death: ___/___/____ (D, M, Y)
Alive
Dead, date of death: ___/___/____ (D, M, Y)
Alive
Dead, date of death: ___/___/____ (D, M, Y)

___/___/___ - ___/___/___
___/___/___ - ___/___/___
___/___/___ - ___/___/___

**Contact Types:
(list all that apply)

Yes

1 – Touched the body fluids of the case (blood, vomit, saliva, urine, feces)
2 – Had direct physical contact with the body of the case (alive or dead)
3 – Touched or shared the linens, clothes, or dishes/eating utensils of the case
4 – Slept, ate, or spent time in the same household or room as the case

2. Did the patient attend a funeral before becoming ill?
Yes
No
Unk
If yes, please complete one line of information for each funeral attended:
Name of Deceased Person Relation to Patient

Dates of Funeral
Attendance (D, M, Yr)

Village

District

Did the patient participate
(carry or touch the body)?

___/___/____ - ___/___/____

Yes

No

___/___/____ - ___/___/____

Yes

No

3. Did the patient travel outside their home or village/town before becoming ill?
Yes
No
Unk
If yes, Village: __________________________ District: ______________________ Date(s): ___/___/____ - ___/___/____
4. Was the patient hospitalized or did he/she go to a clinic or visit anyone in the hospital before this illness?
If yes, Patient Visited: ____________________ Date(s): ___/___/____ - ___/___/____ (D, M, Yr)

Yes

(D, M, Yr)

No

Unk

Health Facility Name: _________________________ Village: _____________________ District: _______________________
5. Did the patient consult a traditional/spiritual healer before becoming ill?

Yes

No

Unk

If yes, Name of Healer: _____________________Village: _______________ District: _____________ Date: ___/___/____ (D, M, Yr)
6. Did the patient have direct contact (hunt, touch, eat) with animals or uncooked meat before becoming ill?
If yes, please tick all that apply:
Animal:
Status (check one only):
Bats or bat feces/urine
Healthy
Sick/Dead
Primates (monkeys)
Healthy
Sick/Dead
Rodents or rodent feces/urine
Healthy
Sick/Dead
Pigs
Healthy
Sick/Dead
Chickens or wild birds
Healthy
Sick/Dead
Cows, goats, or sheep
Healthy
Sick/Dead
Other; specify______________
Healthy
Sick/Dead
7. Did the patient get bitten by a tick in the past 2 weeks?

Section 5.

Yes

No

Yes

No

Unk

Unk

Clinical Specimens and Laboratory Testing

Specimen/shipping instructions:  Label sample with patient name, date of collection, and case ID

 Send sample cold with a cold/ice pack, and packaged appropriately.
 Collect whole blood in a purple top (EDTA) tube – green or red top tubes
acceptable if purple not available
 Preferred sample volume = 4ml (minimum sample volume = 2ml)

Has this patient had a sample submitted previously?
Sample 1:

Yes

Do not complete
UVRI Only

Sample 2:

Sample Collection Date: ____/____/______

(D, M, Yr)

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

Section 6.

No
Do not complete
UVRI Only

Sample Collection Date: ____/____/______ (D, M, Yr)
Sample Type:
Whole Blood
Post-mortem heart blood
Skin biopsy
Other specimen type, specify: ________________

Case Report Form Completed by:

Name: ______________________________ Phone: _________________________ E-mail: _______________________________
Position: _____________________________ District: _____________________ Health Facility: ____________________________
Information provided by:
Patient
Proxy; If proxy, Name:______________________ Relation to Patient: ___________________

Outbreak
Case ID:

Case
Name:

**If the patient is deceased or has already recovered from illness, please fill out the next section.
**If the patient is currently admitted to the hospital, leave the next section blank (it will be completed upon discharge)

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: ____/____/_____ (D, M, Yr)
Final Status of the Patient:

Alive

Dead

Did the patient have signs of unexplained bleeding at any time during their illness?
Yes
No
Unk
If yes, please specify: _______________________________________________________________________________
If the patient has recovered and been discharged from the hospital:
Name of hospital discharged from: _______________________________ District: _________________________________
If the patient was isolated, Date of discharge from the isolation ward: ____/____/______ (D, M, Yr)
Date of discharge from the hospital: ____/____/______

(D, M, Yr)

If the patient is dead:
Date of Death: ____/____/______ (D, M, Yr)
Place of Death:
Community
Hospital: _______________________
Other: ________________________________
Village: _______________________ District: _________________________ Sub-County: _______________________
Date of Funeral/Burial: ____/____/______ (D, M, Yr)
Funeral conducted by:
Family/community
Outbreak burial team
Place of Funeral/Burial:
Village: _______________________ District: _________________________ Sub-County: _______________________
Please tick an answer for ALL symptoms indicating if they occurred at any time during this illness including during hospitalization:

Fever
If yes, Temp: ____º C Source:

Yes
Axillary

Vomiting/nausea
Diarrhea
Intense fatigue/general weakness
Anorexia/loss of appetite
Abdominal pain
Chest pain
Muscle pain
Joint pain
Headache
Cough
Difficulty breathing
Difficulty swallowing
Sore throat
Jaundice (yellow eyes/gums/skin)
Conjunctivitis (red eyes)
Skin rash
Hiccups
Pain behind eyes/sensitive to light
Coma/unconscious
Confused or disoriented

Oral

No

Unk

Rectal

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk

Other non-hemorrhagic clinical symptoms:
Yes
No
If yes, please specifiy: ____________________________

Unk