Case Investigation Form

SARS-CoV-2 Epidemiologic Data Collections

3. Case Investigation Form_instrument_OMB_updated_04.23.20

General Public - Case Investigation Form

OMB: 0920-1297

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nCoV ID: Shape3 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:_________________

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

  2. Age: ____________ Age units: Years Months Days

  3. Sex: Male Female

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

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

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

  7. Country of Residence: United States Other, specify_________________

  8. Occupation:__________________________________________

If student, what grade level? __________________________________________

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


Travel history

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

Yes No Unknown

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

Yes No Unknown

  1. 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

  1. 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) ____________

  1. 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):___________________

  1. 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): ___________________

  1. 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:____________________



  1. 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)




  1. 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

  1. 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 1st HH as A, the 2nd 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

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

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

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

  1. 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

  1. 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:


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

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

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

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

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

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


Social history

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

  2. 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)

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

  4. 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

  1. 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)

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

If yes, how many days during illness? __________

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

  2. 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


  1. 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

  1. Hospital name: ____________________________________________________ Hospital phone: _____________________________

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

  3. To where was the patient discharged?

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

  1. 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

  1. To where was the patient discharged?

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

  1. 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

  1. 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: ______

  2. 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)

  1. 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





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

Yes No Unknown

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

Yes No Unknown

  1. Clinical Discharge Diagnoses and ICD10 Discharge Codes

    Clinical Discharge Diagnoses

    ICD-10-CM Code

    1.


    2.


    3.


    4.


    5.


    6.


    7.


    8.


    9.


    10.


  2. 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

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

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

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

  1. 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


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

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

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

  1. 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

  1. 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



  1. 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: ______________________

____/____/________



  1. 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

  1. 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) _______________________________________________________________

Shape1
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).

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPham, Huong T. (CDC/OID/NCHHSTP) (CTR)
File Modified0000-00-00
File Created2021-01-14

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