Form 0920-1011 2019 nCoV Case Report Form

Emergency Epidemic Investigation Data Collections - Expedited Reviews (Y3Q4)

Appendix 1 2019-nCoV Case Report Form (revised) (002)

2019-nCoV Investigation, United States, 2020

OMB: 0920-1011

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Form Approved: OMB: 0920-1011 Exp. 4/23/2020

Shape13

Human Infection with 2019-Novel Coronavirus (2019-nCoV) Case Report Form



Shape1

State/local ID: _________ CDC ID:_____________ Dash sticker:

Shape2 Shape3 Shape4 Shape5 Shape6 Shape7

_________

:_____________________

____________________

Household ID: _________Cluster ID:______________

Interviewer Information

Date interview completed: / / (MM/DD/YYYY) Date reported to health department: / / (MM/DD/YYYY)

Interviewer Name:________________________________________________ State/Local Health Department___________________________________

Who is providing information for this form?

Case-patient

Other, specify name: ______________________________ Relationship to case patient: ____________________________________

Case-patient primary language: _________________________ Was this form administered via a translator? □ Yes □ No

Case-Patient Information


Last Name: _________________________________________

First Name: ______________________________________________



Current Address: _________________________________

City:

_______________

State:

______________________

Zip:

______________________



Phone No. 1: _______________________

Phone No. 2:________________________

Other point of contact name:_________ __________________

Other point of contact Phone: Relationship to case patient: ____________________________________



Date reported to health department: / / (MM/DD/YYYY)

At the time of this report, is this patient a 2019-nCoV laboratory-confirmed case? Yes No


Demographic information

  1. Date of birth: / / (MM/DD/YYYY)

  2. Age: _______ years months

  3. Current residence: Country: _________ State:______________County___________City______________

  4. Living situation at time of illness: Private residence Military base Shelter Nursing home/long-term healthcare facility School dormitory Homeless Detention facility Other: _______________

  5. Ethnicity: Hispanic or Latino Not Hispanic or Latino

  6. Race (Select all that apply): White Asian American Indian/Alaska Native Black or African American Native Hawaiian/Other Pacific Islander

  7. Sex: Male Female

  8. Is the patient a healthcare worker? Yes No Unknown

  9. Occupation

    Clinical Presentation and Course

  10. Date of first symptom onset __/___/_____ (MM/DD/YYYY)

  11. Does the patient still have symptoms?

Shape8 Shape9 Shape10 Yes No Unknown

  1. When did the patient feel back to normal? / / (MM/DD/YYYY)

  2. During this illness, did the patient experience any of the following?

Symptom

Symptom Present?

Date of Onset (MM/DD/YY)

Duration (no. of days)

Fever >100.4F (38C)

Yes No Unk



Highest temp________ °F




Subjective fever (felt feverish)

Yes No Unk



Chills

Yes No Unk



Cough (new onset or worsening of chronic cough)

Yes No Unk



Dry

Yes No Unk



Productive

Yes No Unk



Bloody sputum (hemoptysis)

Yes No Unk



Sore throat

Yes No Unk



Wheezing

Yes No Unk



Shortness of breath (dyspnea)

Yes No Unk



Swollen lymph nodes (lymphadenopathy)

Yes No Unk



Apnea

Yes No Unk



Runny nose (rhinorrhea)

Yes No Unk



Eye redness (conjunctivitis)

Yes No Unk



Ear pain

Yes No Unk



Rash

Yes No Unk



Abdominal pain

Yes No Unk



Nausea

Yes No Unk



Vomiting

Yes No Unk



Diarrhea (>3 loose stools/day)

Yes No Unk



Chest Pain

Yes No Unk



Muscle aches (myalgia)

Yes No Unk



Headache

Yes No Unk



Dizziness

Yes No Unk



Fatigue

Yes No Unk



Altered Mental Status

Yes No Unk



Seizures

Yes No Unk



Other, specify:

Yes No Unk



Other, specify:

Yes No Unk




  1. Did the patient seek medical care for this illness? Yes No Unk

If, yes which type of facility: (Check all that apply) Outpatient clinic Urgent Care Emergency department Hospital

  1. Was the patient hospitalized for the illness? (if yes, complete hospital form) Yes No Unknown

  2. Is the patient still hospitalized for this illness? Yes No Unknown

  3. Did the patient have an abnormal chest x-ray? Yes No Unk Not performed

  4. Did the patient receive supplemental oxygen? Yes No Unk

  5. Was the patient admitted to the intensive care unit (ICU)? Yes No Unk

  6. Did the patient receive mechanical ventilation? Yes No Unk

  7. Was the patient on extra corporeal membranous oxygen (ECMO)? Yes No Unk

  8. Patient outcome due to illness: Survived Died Unk

    Medical History

  9. Does the patient have any of the following chronic medical conditions? Please specify ALL conditions that qualify.

    Chronic Lung Disease

    Asthma/reactive airway disease

    Yes

    No

    Unknown


    Other chronic lung disease

    Yes

    No

    Unknown

    (If YES, specify)

    Diabetes Mellitus





    Diabetes Mellitus Type 1

    Yes

    No

    Unknown


    Diabetes Mellitus Type 2

    Yes

    No

    Unknown


    Hypertension

    Yes

    No

    Unknown


    Chronic heart or cardiovascular disease

    Yes

    No

    Unknown

    (If YES, specify)

    Chronic kidney disease

    Yes

    No

    Unknown

    (If YES, specify)

    Liver disease

    Yes

    No

    Unknown

    (If YES, specify)

    Non-cancer immunosuppressive condition or treatment

    Yes

    No

    Unknown

    (If YES, specify)

    Cancer chemotherapy in past 12 months

    Yes

    No

    Unknown

    (If YES, specify)

    Neurologic/neurodevelopmental disorder

    Yes

    No

    Unknown

    (If YES, specify)

    Other, specify:

    Yes

    No

    Unknown

    (If YES, specify)

  10. Was patient pregnant at illness onset?

Yes, weeks pregnant at onset No Unknown

  1. Was patient ≤6 weeks postpartum at illness onset?

Yes, postpartum (delivery date) ___/___/___ (MM/DD/YYYY) No Unknown


  1. Has the patient ever smoked? Yes No Unknown

  2. Does the patient currently smoke? Yes No Unknown

  3. Does the patient currently smoke e-cigarettes? Yes No Unknown

2019-nCoV Laboratory Testing (For each specimen type, please report earliest positive specimen, or earliest collected if all negative)

Specimen Type

Date of Collection

Test Result

NP Swab

__/__/____ (MM/DD/YYYY)

Positive Negative Indeterminate Pending

OP Swab

__/__/____ (MM/DD/YYYY)

Positive Negative Indeterminate Pending

Sputum

__/__/____ (MM/DD/YYYY)

Positive Negative Indeterminate Pending

Bronchoalveolar lavage (BAL) fluid

__/__/____ (MM/DD/YYYY)

Positive Negative Indeterminate Pending

Tracheal fluid

__/__/____ (MM/DD/YYYY)

Positive Negative Indeterminate Pending

Stool

__/__/____ (MM/DD/YYYY)

Positive Negative Indeterminate Pending

Urine

__/__/____ (MM/DD/YYYY)

Positive Negative Indeterminate Pending

Serum

__/__/____ (MM/DD/YYYY)

Positive Negative Indeterminate Pending

Other, specify____

__/__/____ (MM/DD/YYYY)

Positive Negative Indeterminate Pending


Exposure

  1. In the 14 DAYS prior to illness, did the case-patient travel outside of the United States? Yes No Unknown

If yes, city___________ state/province _________ country______________ Dates of travel: (MM/DD/YYYY) ___/___/___ - ___/___/___

If yes, city___________ state/province _________ country______________ Dates of travel: (MM/DD/YYYY) ___/___/___ - ___/___/___

If yes, city___________ state/province _________ country______________ Dates of travel: (MM/DD/YYYY) ___/___/___ - ___/___/___

  1. In the 14 DAYS prior to illness, did the case-patient travel outside of their state of residence? Yes No Unknown

If yes, city___________ county _________ state___________ Dates of travel: (MM/DD/YYYY) ___/___/___ - ___/___/___

If yes, city___________ county _________ state___________ Dates of travel: (MM/DD/YYYY) ___/___/___ - ___/___/___

If yes, city___________ county _________ state___________ Dates of travel: (MM/DD/YYYY) ___/___/___ - ___/___/___

  1. In the 14 DAYS prior to illness, did the patient:

    Have close contact with a confirmed 2019-nCoV case-patient?

    Yes

    No

    Unknown

    Have close contact with any household members, friends, acquaintances, or co-workers who had symptoms like the case-patient’s?

    Yes

    No

    Unknown

    Visit a live animal market? If yes, specify __________________________________


    Yes

    No

    Unknown

    Work or volunteer in a healthcare setting?

    Yes

    No

    Unknown

    Visit a healthcare setting?

    Yes

    No

    Unknown

  2. Was this patient under active or passive monitoring following exposure to a confirmed 2019-nCoV case-patient?

Yes No Unknown


Public reporting burden of this collection of information is estimated to average 30 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).

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