Middle East Respiratory Syndrome (MERS) Patient Under In

Form Approved, OMB No. 0920-0004

Middle East Respiratory Syndrome (MERS) Patient Under Investigation (PUI) Short Form
As soon as possible, notify and send completed form to: 1) your local/state health department, and 2) CDC: email ([email protected], subject line:
MERS Patient Form) or fax (770-488-7107). If you have questions, contact the CDC Emergency Operations Center (EOC) at 770-488-7100. This
information can also be entered via online portal at: https://wwwn.cdc.gov/MERS_PUI/Default.aspx
Today’s Date: ___________________ STATE ID: ___________________ STATE: __________ COUNTY: ______________________________
Interviewer’s Name: _________________________________ Phone: _____________________ Email: ________________________________
Sex:
M
F Age: _________
yr
mo Residency:
US resident
non-US resident, country: _________________________________
Date of symptom onset: _______________________ Symptoms (mark all that apply):
Shortness of breath

Muscle aches

Vomiting

Diarrhea

Fever

Chills

Cough

Sore throat

Other: __________________________________________________________

In the 14 days before symptom onset did the patient (mark all that apply):
1
Have close contact with a known MERS case?
1

2

Have close contact with an ill traveler from the Arabian Peninsula/neighboring country ? If Yes, countries: _______________________________
2

Visit or work in a health care facility in the Arabian Peninsula/neighboring country ? If Yes, countries: ____________________________________
2

Travel to/from the Arabian Peninsula/neighboring country ? If Yes, countries: _______________________________________________________
Date of travel TO this area: ______________________________

Date of travel FROM this area: ____________________________________

Is the patient a member of a severe respiratory illness cluster of unknown etiology?
Is the patient a health care worker (HCW)?

Yes

2

Peninsula in the 14 days before symptom onset?

No
Yes

Chronic pulmonary disease

No

Unknown

Unknown If Yes, did the patient work as a HCW in/near a country in the Arabian
No

Unknown If Yes, countries: __________________________________________

Does the patient have any comorbid conditions? (mark all that apply):
Asthma

Yes

Immunocompromised

None

Unknown

Diabetes

Cardiac disease

Other: _______________________________________________________
Yes

Was the patient: Hospitalized? If Yes, admission date: ________________________________
Admitted to the Intensive Care Unit (ICU)?
Intubated?
Did the patient die? If Yes, date of death: _________________________________
Did the patient have clinical or radiologic evidence of pneumonia?
Did the patient have clinical or radiologic evidence of acute respiratory distress syndrome (ARDS)?
General non-MERS-CoV Pathogen Laboratory Testing (mark all that apply)
Pathogen
Pos
Neg Pending Not Done Pathogen
Influenza A PCR
Rhinovirus and/or Enterovirus
Influenza B PCR
Coronavirus (not MERS-CoV)
Influenza Rapid Test
Chlamydophila pneumoniae
RSV
Mycoplasma pneumoniae
Human metapneumovirus
Legionella pneumophila
Parainfluenzavirus
Streptococcus pneumoniae
Adenovirus
Other: ____________________
MERS-CoV rRT-PCR Testing (mark all that apply)
Specimen Type
Sputum
Bronchoalvelolar lavage (BAL)
Tracheal Aspirate
3
3
3
NP
OP
NP/OP
(circle one)
Serum
Other: ________________________________
MERS-CoV Serology Testing

Hypertension

Pos

No

Unknown

Neg

Pending

Not Done

Not Done

Date Collected

Positive

Negative

Equivocal

Pending

Date Collected

Positive

Negative

Pending

Not Done

1
Close contact is defined as: a) being within approximately 6 feet (2 meters) or within the room or care area for a prolonged period of time (e.g., healthcare personnel, household
members) while not wearing recommended personal protective equipment (i.e., gowns, gloves, respirator, eye protection); or b) having direct contact with infectious secretions (e.g.,
being coughed on) while not wearing recommended personal protective equipment. Data to inform the definition of close contact are limited. At this time, brief interactions, such as
walking by a person, are considered low risk and do not constitute close contact.
2
Countries considered in the Arabian Peninsula and neighboring include: Bahrain; Iraq; Iran; Israel, the West Bank and Gaza; Jordan; Kuwait; Lebanon; Oman; Qatar; Saudi Arabia;
Syria; the United Arab Emirates (UAE); and Yemen.
3 NP = nasopharyngeal, OP = oropharyngeal (throat swab)
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-24, Atlanta, Georgia 30333; ATTN: PRA (0920-0004).

Version 7.0, March 24, 2017