Form 0920-1011 2019 nCoV Case Report Form

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

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

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

_________

:_____________________

____________________

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?

Yes No Unknown

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

13. 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

14. 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

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

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

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

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

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

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

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

22. Patient outcome due to illness: Survived Died Unk

    Medical History

23. 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)

24. Was patient pregnant at illness onset?

Yes, weeks pregnant at onset No Unknown

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

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

26. Has the patient ever smoked? Yes No Unknown

27. Does the patient currently smoke? Yes No Unknown

28. 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

29. 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) ___/___/___ - ___/___/___

30. 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) ___/___/___ - ___/___/___

31. 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

32. 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).