Middle East Respiratory Syndrome Coronavirus (MERS) Pati

National Disease Surveillance Program - II. Disease Summaries

Att X_Middle East Respiratory Syndrome Coronavirus (MERS) Patient Under Investigation (PUI) Form

Att X Middle East Respiratory Syndrome Coronavirus (MERS) Patient Under Investigation (PUI) Form

OMB: 0920-0004

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Middle East Respiratory Syndrome Coronavirus (MERS) Patient Under Investigation (PUI) Form

Form Approved OMB 0920-0004, Exp Date 08/31/2014

For PUI, complete and send this form to [email protected] (subject line: MERS Form) or fax to 770-488-7107.

If you have questions contact the CDC Emergency Operations Center (EOC) at 770-488-7100.

STATE ID:

Today’s Date: MM/DD/YY

County:

City:

State:

Interviewer’s name:

Phone:

Email:

Physician’s name:

Phone/Pager:


PUI Definition—Does the patient have:

(Please consult CDC website at http://www.cdc.gov/coronavirus/mers/case-def.html)

1. Acute respiratory infection with fever (≥ 38oC, 100.4oF) and cough? Yes No Unknown

2. Clinical or radiographic evidence of pneumonia or acute respiratory distress syndrome (ARDS)? Yes No Unknown

3. Travel from the Arabian Peninsula or neighboring countries 14 days before illness onset? Yes No Unknown

If yes, which countries?_________________________________ Date of travel to/from the Middle East: MM/DD/YY|MM/DD/YY

Patient Demographic Information

1. Sex: M F 2. Age:_____ yr mo 3. Residency: US resident non US resident, country:_______________

Clinical Presentation, History and Risk Factors

4. Date of symptom onset: MM/DD/YY

5. Symptoms (Check all that apply): Fever Dry cough Productive cough Chills Sore throat Headache Muscle aches Shortness of breath Vomiting Abdominal pain Diarrhea Other_________________________

6. In the 14 days before symptom onset did the patient have close contact with a recent ill traveler from the Arabian Peninsula or neighboring countries? Yes No Unknown If yes, which countries?_________________________________________

7. Is the patient (Check all that apply): Health care worker (HCW) US military Flight crew Other_______________

8. Concurrent risk factors (Check all that apply): Immunocompromised Pregnant Unknown

Other_____________________________________________________________________________________________________

Clinical Outcomes

9. Is/Was the patient:

a. Hospitalized?

b. Admitted to ICU?

c. Intubated?


Yes No Unknown If yes, date: MM/YY/DD

Yes No Unknown

Yes No Unknown

10. Is/Has patient receiving/received a diagnosis of:

Pneumonia?

ARDS?

Renal failure?

Yes No Unknown

Yes No Unknown

Yes No Unknown

11. Does the patient have a non-MERS etiology for their respiratory illness but has not responded to appropriate therapy? Yes No Unknown

12. Has the patient died?

Yes No Unknown

Infection Control

13. When hospitalized, is/was the patient in a:

14. Are/Were surgical masks being used by the patient during transport?

Yes No Unknown

a. Negative pressure room?

b. Private room?

Yes No Unknown

Yes No Unknown

15. What personal protective equipment are/were being used by HCW when entering the patient’s room (Check all that apply):

Gloves Gowns Eye protection (goggles or face shield) N95/other form of respiratory protection (e.g., PAPR)

Facemask Unknown







Laboratory Testing

Tests Performed

Results

Tests Performed

Results


+

̶

Pending (Pe)

Not done

+

̶

Pending (Pe)

Not done

Influenza A B



Streptococcus pneumoniae



RSV



Legionella pneumophila



Human metapneumovirus



Blood culture

If positive_________________



Parainfluenza 1-4



Adenovirus



Other:____________________



MERS Testing

Specimen

ID #

Date collected

State

Sent to CDC?

Specimen

ID #

Date collected

State

Sent to CDC?


+

̶

Pe

+

̶

Pe


NP/OP


MM/DD/YY



PF


MM/DD/YY




Sputum


MM/DD/YY



Stool


MM/DD/YY




BAL


MM/DD/YY



Serum


MM/DD/YY




TA


MM/DD/YY





MM/DD/YY






NP/OP, Nasopharyngeal/Oropharyngeal swab; BAL, Bronchoalveolar lavage; TA, Tracheal aspirate; PF, Pleural fluid


Countries considered in the Arabian Peninsula and neighboring include: Bahrain, Iraq, Iran, Israel, Jordan, Kuwait, Lebanon, Oman, Palestinian territories, Qatar, Saudi Arabia, Syria, the United Arab Emirates (UAE), and Yemen.

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 Information Collection Review Office,1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0004). Version 5.5, 7/3/13


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorLloyd, Spencer (CDC/CGH/DGHA)
File Modified0000-00-00
File Created2021-01-23

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