Middle East Respiratory Syndrome Coronavirus (MERS) Pati

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