Homeless Symptom Follow-Up

SARS-CoV-2 Epidemiologic Data Collections

10. Homeless_ symptom follow-up_instrument_OMB (omB)_ko

Homeless Shelter Staff - Homeless Symptom Follow-Up

OMB: 0920-1297

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Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

Version 7 February 20

Human Infection with 2019 Novel Coronavirus (2019-nCoV)

Homeless Study Follow-up Investigation Form



State: ______________ Source Case state/local ID: ______________

State/local health dept.: ______________ Source Case CDC 2019-nCoV ID b: ______________

Contact ID a: ______________ Contact 2019-nCoV IDc: ______________

  1. Assign Contact ID using CDC 2019-nCoV ID and sequential contact ID, e.g., Confirmed case 0023CA has contacts 0023CA-001 and 0023CA-002

  2. Complete with ID of the associated confirmed case who identified this contact

  3. To be assigned at CDC


Interviewer instructions: prior to interview with contact, please note the following information about the confirmed 2019-nCoV case that identified this contact:


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


Name:_________________________________



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

Case Identification number____________________________________________________







Demographic information

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

  2. Age: _______ years months

  3. Current residence: Country: _________ State:______________County___________City______________

  4. Ethnicity: Hispanic or Latino Not Hispanic or Latino

  5. Race: White Asian American Indian/Alaska Native Black or African American Native Hawaiian/Other Pacific Islander

  6. Sex: Male Female

Symptoms

  1. In the past day, have you experienced any of the following symptoms?

Symptom

Symptom Present?

Duration (no. of days)

Systemic



Fever >100.4F (38C)

Yes No Unk


Subjective fever (felt feverish)

Yes No Unk


Cough (new onset or worsening of chronic cough)

Yes No Unk


Shortness of breath (dyspnea)

Yes No Unk


Vomiting

Yes No Unk


Nausea

Yes No Unk


Diarrhea (≥3 loose/looser than normal stools/24hr period)

Yes No Unk














Medical History

  1. Do you have any of the following:


Chronic Lung Disease

Yes

No

Unknown

Specify:

Smoking

Yes, current

Yes, former

No

Unknown

Active tuberculosis

Yes

No

Unknown


Diabetes Mellitus

Yes

No

Unknown

Specify:

Cardiovascular disease

Yes

No

Unknown

Specify:

Renal disease

Yes

No

Unknown

Specify:

Liver disease

Yes

No

Unknown

Specify:

Immunocompromised Condition

Yes

No

Unknown

Specify:

Neurologic/neurodevelopmental disorder

Yes

No

Unknown

Specify:

Other chronic diseases

Yes

No

Unknown

Specify:





Social History



  1. Have you been to a shelter in the last 2 weeks (14 days) before your symptoms started or your test was positive? (Any of the symptoms listed above)

If yes, name of shelters where you have slept? ______________________________________

If not in shelters, where have you slept? ___________________________________________

  1. Where have you eaten your meals in the last 2 weeks (14 days) before your symptoms started or your test was positive?

Names of places you went to get your meals ______________________________________________

  1. Have you been to any places in the last 2 weeks (14 days) to hang out or be with other people?

___________________________________________________________________________________

  1. Did you receive any other services in the last 2 weeks (14 days) before your symptoms or your test was positive started? (Examples: Day shelters, shower/bathroom/lockers, case management, job placement/training)

Names of places______________________________________________________________________

  1. Did you receive any medical services in the last 2 weeks (14 days) before your symptoms started or your test was positive? (Examples: mobile clinic, hospitals, ER, clinic)

____________________________________________________________________________________

  1. Did you have a court date or stay in a correctional facility in the 2 weeks (14 days) before your symptoms started or your test was positive?

____________________________________________________________________________________











Laboratory testing


27. If yes, what type of specimen was collected?


Specimen Type

ORIGINAL Specimen ID

NP swab


OP swab



Nasal swab





This is the end of the case report 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]

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Public reporting burden of this collection of information is estimated to average 5 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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