Case Investigation Form

nCoV ID: Form Approved: OMB: 0920-XXXX Exp. X/XX/XXXX

……………PATIENT IDENTIFIER INFORMATION IS NOT TRANSMITTED TO CDC……………………

Patient first name _______________ Patient last name __________________ Date of birth (MM/DD/YYYY): ____/_____/_______

……………PATIENT IDENTIFIER INFORMATION IS NOT TRANSMITTED TO CDC……………………

C OVID-19 Case Investigation Form

Reporting jurisdiction: ______________ Case state/local ID: ______________

Reporting health department: ______________ CDC 2019-nCoV ID: ______________

Contact ID a: ______________ NNDSS loc. rec. ID/Case ID b: ______________

1. a. Only complete if case-patient is a known contact of prior source case-patient. Assign Contact ID using CDC 2019-nCoV ID and sequential contact ID, e.g., Confirmed case CA102034567 has contacts CA102034567 -01 and CA102034567 -02. bFor NNDSS reporters, use GenV2 or NETSS patient identifier.

Interviewer information

Name of interviewer: Last ______________________________ First______________________________________

Affiliation/Organization: ____________________________________________

Telephone ______________________________ Email _______________________________________________

Date of interview: ________________(MM/DD/YYYY) Date of medical chart abstraction: _________________ (MM/DD/YYYY)

Data sources used for this form?

Case-patient interview Other interview, specify relationship to case:_______________________ Medical Chart Abstraction

Case-patient’s primary language: ____________________ Was this form administered via a translator? □ Yes □ No □ Unknown

Case-patient demographic information

1. Report date to CDC (MM/DD/YYYY): ____/_____/_______

2. Under what process was the case first identified? (check all that apply): PUI/sought care for acute illness Contact tracing of case patient Surveillance system, please specify:___________________________

EpiX notification of travelers; if checked, DGMQID_______________ Unknown Other, specify:_________________

3. Date of birth (month and year): Month ____ Year _____

4. Age: ____________ Age units: Years Months Days

5. Sex: Male Female

6. Ethnicity: Hispanic/Latino Non-Hispanic/Latino Not specified

7. Race (check all that apply): White Asian American Indian/Alaska Native Black
   Native Hawaiian/Other Pacific Islander Unknown Other, specify: _________________

8. County of Residence:________________________ State of Residence:________

9. Country of Residence: United States Other, specify_________________

10. Occupation:__________________________________________

If student, what grade level? __________________________________________

If child, does s/he attend day care? Yes No Unknown

Travel history

11. In the 14 days prior to illness onset, were you traveling away from your home internationally?

Yes No Unknown

12. In the 14 days prior to illness onset, were you traveling away from your home within the United States?

Yes No Unknown

13. Where did you travel 14 days prior to illness onset (list ALL locations, including overnight transits and layovers)?

	Departure Date (MM/DD/YYYY)	Departure city, state/province/country	Arrival Date (MM/DD/YYYY)	Arrival city, state/province/country
Trip 1
Trip 2
Trip 3
Trip 4
Trip 5

Exposure history

14. In the 14 DAYS prior to illness, did you have close contact with another lab-confirmed COVID-19 case-patient?

Yes No Unknown Date Range: Start Date (MM/DD/YYYY) ____________ End Date (MM/DD/YYYY) ____________

15. Relationship to COVID-19 source case (select all that apply):

Spouse/Partner Child Parent Other Family Friend HCW Co-worker
Classmate Roommate Contact only – no relationship Other (specify):___________________

16. Exposure setting to the COVID-19 source case (select all that apply):

Household Work Daycare School/University Transit Rideshare Hotel Cruise Ship

Healthcare Other (specify): ___________________

17. In the 14 DAYS prior to illness onset, did you:

Exposure	Answer	Date Range
…have any household members, friends, acquaintances, or co-workers who had fever or respiratory symptoms (e.g. cough, sore throat etc.)?	Yes No Unknown
…have close contact (e.g. caring for, speaking with, or touching) with any ill persons?	Yes No Unknown
…attend a mass gathering (e.g., religious event, wedding, party, dance, concert, banquet, festival, sports event, or other event)?	Yes No Unknown
…use public transportation (bus, train, airplane)?	Yes No Unknown
…attend or work at a school or daycare?	Yes No Unknown
…have a household member who attended school or daycare?	Yes No Unknown
…have close contact (e.g. caring for, speaking with, or touching) with a sick person who had contact with a COVID-19 patient (i.e., secondary contact to confirmed case)?	Yes No Unknown
…have close contact (e.g. caring for, speaking with, or touching) with a person who had a fever and/or acute respiratory illness and international travel in the past 2 weeks?	Yes No Unknown If yes where did the person travel:____________________

18. In the 14 DAYS prior to illness onset, did you:

Exposure	Y/N/Unk	Facility type (Select all that apply)			Date(s) exposure occurred
Work in healthcare setting:	Y N Unk If yes, what was your role: Physician Nurse Administration staff Housekeeping Patient transport Other, specify__________	Hospital Urgent Care Doctor’s office/clinic		Dialysis unit/center Long Term Care Facility Other (specify)
Volunteer in healthcare setting	Y N Unk	Hospital Urgent Care Doctor’s office/clinic		Dialysis unit/center Long Term Care Facility Other (specify)
Have direct patient contact	Y N Unk	Hospital Urgent Care Doctor’s office/clinic		Dialysis unit/center Long Term Care Facility Other (specify)
Visit healthcare setting as a patient (not just for this illness)	Y N Unk	Hospital Urgent Care Doctor’s office/clinic		Dialysis unit/center Long Term Care Facility Other (specify)
Visit healthcare setting for any reason other than as a patient	Y N Unk	Hospital Urgent Care Doctor’s office/clinic		Dialysis unit/center Long Term Care Facility Other (specify)
Contact with a known COVID-19 case-patient in a healthcare setting	Y N Unk If yes, as a Patient Visitor HCW	Hospital Urgent Care Doctor’s office/clinic	Dialysis unit/center Long Term Care Facility Other (specify)

19. Do you reside in an institutional or group setting (e.g. long-term care facility/nursing home, boarding school, college dormitory, etc.)?

Yes No Unknown

20. How many people in total resided in your household (HH) from the 14 days prior to illness through the date of this interview (excluding you)? ________. A household member is anyone with at least one overnight stay during the 14 days prior to patient’s illness onset to the date of this interview. If patient belongs to multiple HH, group HH members by identifying the 1^st HH as A, the 2^nd HH as B, etc.

HH (if case-patient belongs to >1 HH)	Relation to patient	Sex M/F	Age (specify unit as years, months, or days)	Did household member have fever or respiratory symptoms (e.g. cough, sore throat, etc.) in the 14 days prior to patient’s illness onset, during the patient’s illness, or 14 days after patient’s illness?	Date of illness onset of household member (MM/DD/YYYY)
A B C				Y N Unk
A B C				Y N Unk
A B C				Y N Unk
A B C				Y N Unk
A B C				Y N Unk
A B C				Y N Unk
A B C				Y N Unk

Symptoms

21. If symptomatic, onset date of first symptom (MM/DD/YYYY): ____/_____/_______ Unknown Asymptomatic

22. If experienced symptoms, are you Still symptomatic Unknown symptom status Symptoms resolved

If symptoms resolved, date of symptom resolution (MM/DD/YYYY): ____/_____/_____ Unknown date

23. During this illness, did you experience any of the following symptoms?

Symptom		Symptom
Fever ≥100.4F (38C)	Yes No Unk	Cough (new onset or worsening of chronic cough)	Yes No Unk
Highest temp________ °F		Dry	Yes No Unk
Date of onset (MM/DD/YYYY) ___/___/_______		Productive	Yes No Unk
Duration of fever ≥100.4F (38C) (days) ____________		Bloody sputum (hemoptysis)	Yes No Unk
Subjective fever (felt feverish)	Yes No Unk	Shortness of breath (dyspnea)	Yes No Unk
Chills	Yes No Unk	Wheezing	Yes No Unk
Fatigue	Yes No Unk	Chest Pain	Yes No Unk
Muscle aches (myalgia)	Yes No Unk	Abdominal pain	Yes No Unk
Rash	Yes No Unk	Vomiting	Yes No Unk
Headache	Yes No Unk	Nausea	Yes No Unk
Eye redness (conjunctivitis)	Yes No Unk	Diarrhea (≥3 loose/looser than normal stools/24hr period)	Yes No Unk
Runny nose (rhinorrhea)	Yes No Unk	Poor Feeding/Poor appetite	Yes No Unk
Sore throat	Yes No Unk	Seizures	Yes No Unk
Other, specify:	Yes No Unk	Other, specify:	Yes No Unk

Past medical history

24. Do you have any pre-existing medical conditions? Yes No Unknown

Chronic Lung Disease	Yes	No	Unknown
Asthma/reactive airway disease	Yes	No	Unknown
Emphysema/COPD	Yes	No	Unknown
Other chronic lung disease	Yes	No	Unknown	(If YES, specify)
Active tuberculosis	Yes	No	Unknown
Diabetes Mellitus	Yes	No	Unknown
Cardiovascular disease	Yes	No	Unknown
Hypertension	Yes	No	Unknown
Coronary artery disease	Yes	No	Unknown
Heart failure/Congestive heart failure	Yes	No	Unknown
Cerebrovascular accident/Stroke	Yes	No	Unknown
Congenital heart disease	Yes	No	Unknown
Other	Yes	No	Unknown	If YES, specify:
Renal disease	Yes	No	Unknown
Chronic kidney disease/insufficiency	Yes	No	Unknown
End-stage renal disease	Yes	No	Unknown
Dialysis	Yes	No	Unknown
Other	Yes	No	Unknown	If YES, specify:
Liver disease	Yes	No	Unknown
Alcoholic hepatitis	Yes	No	Unknown
Chronic liver disease	Yes	No	Unknown
Cirrhosis/End stage liver disease	Yes	No	Unknown
Hepatitis B, chronic	Yes	No	Unknown
Hepatitis C, chronic	Yes	No	Unknown
Non-alcoholic fatty liver disease (NAFLD)/NASH	Yes	No	Unknown
Other	Yes	No	Unknown	If YES, specify:
Immunocompromised Condition	Yes	No	Unknown
HIV infection	Yes	No	Unknown
AIDS or CD4 count <200	Yes	No	Unknown
Solid organ transplant	Yes	No	Unknown
Stem cell transplant (e.g., bone marrow transplant)	Yes	No	Unknown
Cancer: current/in treatment or diagnosed in last 12 months	Yes	No	Unknown
Other	Yes	No	Unknown	If YES, specify:
Immunosuppressive therapy	Yes	No	Unknown	If YES, specify:______________________________ __________________________________________ For what condition: _______________________ _________________________________________
Neurologic/neurodevelopmental disorder	Yes	No	Unknown	If YES, specify:
Other chronic diseases	Yes	No	Unknown	If YES, specify:

25. Current height: _________ (inches) OR __________ (cm)

26. Current weight: _________ (pounds) OR __________ (kg)

27. If female, are you currently pregnant? Yes Weeks pregnant at illness onset_________ No Unknown

28. If female, are you postpartum ( 6 weeks postpartum)? Yes No Unknown

29. If female, are you breastfeeding? Yes No Unknown

30. If child, is he/she being breastfed? Yes No Unknown

Social history

31. Do you currently smoke cigarettes? Yes No Unknown
    If yes, how many packs of cigarettes per day? ______ For how many years? _____

32. Have you ever smoked cigarettes? Yes No Unknown
    If yes, how many packs of cigarettes per day? ______ For how many years? _____ How long since you last smoked a cigarette? ___(m) ___(y)

33. Do you currently use e-cigarettes/vape-pen? Yes No Unknown

34. In the past year, how often did you have a drink containing alcohol?

 Never  Monthly or less  2-4 times a month  2-3 times per week  4 or more times per week

Course of Illness

35. Do you feel back to normal? Yes No Not applicable (patient deceased) Not applicable (patient asymptomatic) Unknown

If yes, when did you feel back to normal? _____/_____/_____ (MM/DD/YYYY)

36. Did you miss work or school for this illness? Yes No Unknown

If yes, how many days during illness? __________

37. Did you receive any medical care for the illness? Yes No Unknown

38. If yes, where and which dates did you seek care after this illness started (check all that apply)? [Please add extra visit dates in ‘notes’ box]

Doctor’s office Date 1: ______/_____/_______ (MM/DD/YYYY) Date 2: ______/_____/_______ (MM/DD/YYYY)

Emergency room Date 1: ______/_____/_______ (MM/DD/YYYY) Date 2: ______/_____/_______ (MM/DD/YYYY)

Retail store/pharmacy Date 1: ______/_____/_______ (MM/DD/YYYY) Date 2: ______/_____/_______ (MM/DD/YYYY)

Health department Date 1: ______/_____/_______ (MM/DD/YYYY) Date 2: ______/_____/_______ (MM/DD/YYYY)

Urgent care Date 1: ______/_____/_______ (MM/DD/YYYY) Date 2: ______/_____/_______ (MM/DD/YYYY)

Telephone triage line Date 1: ______/_____/_______ (MM/DD/YYYY) Date 2: ______/_____/_______ (MM/DD/YYYY)

Other __________ Date 1: ______/_____/_______ (MM/DD/YYYY) Date 2: ______/_____/_______ (MM/DD/YYYY)

Unknown

39. Was the patient hospitalized? Yes No Unknown If YES, please fill out hospitalization section below If no, skip to Question #53

Purpose: Clinical indication No clinical indication (e.g., isolation for public health)

Hospitalization

40. Hospital name: ____________________________________________________ Hospital phone: _____________________________

41. If yes, Admission date 1 ___/___/___ (MM/DD/YYYY) , discharge date 1 ___/___/____ (MM/DD/YYYY) Patient still hospitalized

42. To where was the patient discharged?

Home Transferred to another hospital Nursing facility/rehab Hospice Other ______________ Unknown

43. If hospitalized more than once, please enter the second hospitalization’s admission and discharge dates:

Hospital name: ____________________________________________________ Hospital phone: _____________________________

Admission date 2 ______/_____/_______ (MM/DD/YYYY) Discharge date 2______/_____/_______ (MM/DD/YYYY)

Patient still hospitalized

44. To where was the patient discharged?

Home Transferred to another hospital Nursing facility/rehab Hospice Other ______________ Unknown

45. First recorded vital signs: Temp_________ (Unit: °F / ^oC) Blood pressure: ________ (systolic) / ________ (diastolic)

Heart rate: _________ Resp rate:___________

O2 Sat: _______________ (Type of support required when O2 saturation was measured:

Room Air Nasal Cannula Face Mask CPAP or BIPAP High Flow Nasal Cannula Invasive mechanical ventilation

Other, specify: Unknown

Fraction of Inspired Oxygen/Flow __________ % Liters/minute (LPM) Unknown NA

46. First recorded laboratory values for:

    	Date (MM/DD/YYYY)	Value	Unit
    White blood cell (WBC) count			Cells x 109/L x 1 000/μL Other: ______
    Absolute neutrophil count			Cells x 109/L x 1 000/μL Other: ______
    Absolute lymphocyte count			Cells x 109/L x 1 000/μL Other: ______
    Platelets (Plt)			Cells x 109/L x 1 000/μL Other: ______
    Aspartate transaminase (AST)			U/L IU/L Other: ______
    Alanine aminotransferase (ALT)			U/L IU/L Other: ______
    Lactate dehydrogenase (LDH)			U/L IU/L Other: ______

47. Was the patient admitted to an intensive care unit (ICU)? Yes No Unknown

ICU admission date 1 ______/_____/_______ (MM/DD/YYYY) ICU discharge date 1 ______/_____/_______ (MM/DD/YYYY)

ICU admission date 2 ______/_____/_______ (MM/DD/YYYY) ICU discharge date 2 ______/_____/_______ (MM/DD/YYYY)

48. During hospitalization, did the patient receive...

		Start Date (MM/DD/YYYY)	Last Date (MM/DD/YYYY)	Total Days
Supplemental Oxygen?	Y N Unk
BiPaP or CPAP use?	Y N Unk
High flow nasal cannula?	Y N Unk
Invasive mechanical ventilation?	Y N Unk
ECMO?	Y N Unk

49. Did the patient receive a discharge diagnosis of pneumonia (refer to clinical discharge summary)?

Yes No Unknown

50. Did the patient receive a discharge diagnosis of acute respiratory distress syndrome (ARDS) (refer to clinical discharge summary)?

Yes No Unknown

51. Clinical Discharge Diagnoses and ICD10 Discharge Codes

    Clinical Discharge Diagnoses	ICD-10-CM Code
    1.
    2.
    3.
    4.
    5.
    6.
    7.
    8.
    9.
    10.

52. Did the patient receive any antiviral medications during hospitalization for this illness:

Medication		Dose	Frequency	Start Date (MM/DD/YYYY)	Last Date (MM/DD/YYYY)	Total Days
Remdesivir	PO IV IM
Other:____________________	PO IV IM
Other:____________________	PO IV IM

Imaging

53. Was a chest x-ray taken? Yes No Unknown

54. Were any of these chest x-rays abnormal? Yes No Unknown

Date of first abnormal chest x-ray: ______/_____/_______ (MM/DD/YYYY

55. For first abnormal chest x-ray, please check all that apply: Report not available:

Air space density		Cannot rule out pneumonia		ARDS (acute respiratory distress syndrome)		Other
Air space opacity		Consolidation		Lung infiltrate		Pleural Effusion
Bronchopneumonia/pneumonia		Cavitation		Interstitial infiltrate		Empyema

56. Was a chest CT/MRI taken? Yes No Unknown

57. Were any of these chest CT/MRIs abnormal? Yes No Unknown

Date of first abnormal CT/MRI: ______/_____/_______ (MM/DD/YYYY)

58. For first abnormal chest CT/MRI, please check all that apply: Report not available:

Air space density		ARDS (acute respiratory distress syndrome)		Empyema		Englarge epiglottis
Air space opacity/opacification		Lung infiltrate		Pneumothorax		Tracheal narrowing
Bronchopneumonia/pneumonia		Interstitial infiltrate		Pneumomediastinum		Ground glass opacities
Consolidation		Lobar infiltrate		Widened mediastinum		Other
Cavitation		Pleural effusion

Lab Results

59. SARS-CoV-2 Testing (Please report further test results in comments)

Date of sample collection (MM/DD/YYYY)	Sample Type	Result
	NP OP Sputum Other, specify: ___________________	Pos Neg Inconclusive
	NP OP Sputum Other, specify: ___________________	Pos Neg Inconclusive
	NP OP Sputum Other, specify: ___________________	Pos Neg Inconclusive
	NP OP Sputum Other, specify: ___________________	Pos Neg Inconclusive
	NP OP Sputum Other, specify: ___________________	Pos Neg Inconclusive

60. Was patient tested for other viral respiratory pathogens during their illness? Yes (report results below) No Unknown

	Positive	Negative	Not Tested/ Unknown	Collection Date (MM/DD/YYY)	Specimen Type
Flu A/H1				____/____/________
Flu A/H3				____/____/________
Flu B				____/____/________
Flu (no type)
Respiratory syncytial virus/RSV				____/____/________
Adenovirus				____/____/________
Parainfluenza virus 1				____/____/________
Parainfluenza virus 2				____/____/________
Parainfluenza virus 3				____/____/________
Parainfluenza virus 4				____/____/________
Respiratory syncytial virus/RSV				____/____/________
Human metapneumovirus				____/____/________
Rhinovirus/enterovirus				____/____/________
Human coronavirus 229E				____/____/________
Human coronavirus HKU1				____/____/________
Human coronavirus NL63				____/____/________
Human coronavirus OC43				____/____/________
Other, specify: ______________________				____/____/________

61. Were any bacterial culture tests performed during their illness? Yes No Unknown

If yes, was there a positive culture for a bacterial pathogen? Yes No Unknown

If yes, specify pathogen: __________________________________________________

If yes, specify date of culture (MM/DD/YYYY): ____________

If yes, site where pathogen identified: Blood Sputum Bronchoalveolar lavage (BAL) Endotracheal aspirate Pleural fluid

Cerebrospinal fluid (CSF) Other, specify: ______________

If more than one bacterial culture test was performed, please record in additional comments.

Outcome

62. Did the patient die as a result of this illness?

Yes, Date: _____/_____/_____ (MM/DD/YYYY) No Unknown

Where did the death occur: Home Hospital ER Hospice Other, specify______________________________

(If the following information is not currently available, please send an update later using death certificate or death note in hospital record.)

Contribution of COVID-19 to death Underlying/primary Contributing/secondary No contribution to death Unknown

Was autopsy performed? Yes No Unknown

Primary Cause of death (death certificate/coroner) _______________________________________________________________

Any additional comments or notes?

This is the end of the case investigation form. Thank you very much for your time. If you have any questions please feel free to contact the CDC at 770-488-7100 or [email protected]

Public reporting burden of this collection of information is estimated to average 60 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).