Risk Factor Interview

SARS-CoV-2 Epidemiologic Data Collections

12. Risk Factor_Interview0402_instrument_OMB_updated_04.23.20

General Public - Risk Factor Interview

OMB: 0920-1297

Document [docx]
Download: docx | pdf

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


Shape1

Record ID: CO_______________________



Interviewer information

Name of interviewer: Last ______________________________ First______________________________________

Affiliation/Organization: ____________________________________________

Telephone ______________________________ Email _______________________________________________

Date of interview: ________________(MM/DD/YYYY)

Data sources used for this form?

Case-patient interview Other interview, specify relationship to case:_______________________ Case Report Form/CEDRS

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


Case-patient demographic information

  1. Report date to CDPHE: ____/_____/_______

  2. Under what process was the case first identified? (check all that apply): Sought care for acute illness Contact tracing of case patient 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:__________________________________________

Are you currently employed in a laboratory that processes COVID-19 samples? Yes No

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. If “yes” to Q11 or Q12: 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 a facility or group setting (e.g. long-term care facility/nursing home, boarding school, college dormitory, etc.)?

Yes No Unknown

If yes, what type of group setting do you live in? Military base Shelter Nursing home/long-term healthcare facility

Assisted Living Facility Hospice School dormitory Homeless Detention/correctional facility

Foster care group setting Other: ___________________________

  1. If they answered “No” to question 19: 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. What was the onset date of your first symptom (MM/DD/YYYY): ____/_____/_______ Unknown

  2. Are you still having symptoms? Still symptomatic Symptoms resolved Not applicable (patient deceased) Unknown


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



  1. What was the first symptom you experienced? _________________________________________________________

  2. If you received medical care for this illness, what symptom(s) prompted your visit to the doctor or other healthcare professional?

_______________________________________________________________________________ Did not receive medical care

  1. During this illness, did you experience any of the following symptoms? (for each symptom experienced, ask what date that symptom started and how many days that symptom lasted to complete the table below)

Symptom

Symptom Present?

Date of Onset (MM/DD/YY)

Duration (no. of days)

Fever >100.4F (38C)

Yes No Unknown



Highest temp________ °F




Subjective fever (felt feverish)

Yes No Unknown



Chills

Yes No Unknown



Sweats

Yes No Unknown



Dehydration

Yes No Unknown



Cough (new onset or worsening of chronic cough)

Yes No Unknown



Dry

Yes No Unknown



Productive

Yes No Unknown



Bloody sputum (hemoptysis)

Yes No Unknown



Sore throat

Yes No Unknown



Wheezing

Yes No Unknown



Shortness of breath (dyspnea)

Yes No Unknown



Runny nose (rhinorrhea)

Yes No Unknown



Stuffy nose (nasal congestion)

Yes No Unknown



Loss of smell (Anosmia)

Yes No Unknown



Loss of taste (Ageusia)

Yes No Unknown



Swollen Lymph Nodes (Lymphadenopathy)

Yes No Unknown



Eye redness (conjunctivitis)

Yes No Unknown



Rash

Yes No Unknown



Abdominal pain

Yes No Unknown



Vomiting

Yes No Unknown



Nausea

Yes No Unknown



Loss of appetite (anorexia)

Yes No Unknown



Diarrhea (>3 loose stools/day)

Yes No Unknown



Chest Pain

Yes No Unknown



Muscle aches (myalgia)

Yes No Unknown



Joint Pain (Arthralgia)

Yes No Unknown



Headache

Yes No Unknown



Fatigue

Yes No Unknown



Seizures

Yes No Unknown



Altered Mental Status (confusion)

Yes No Unknown



Other, specify:

Yes No Unknown



Other, specify:

Yes No Unknown



Other, specify:

Yes No Unknown



Other, specify:

Yes No Unknown




Past medical history

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

Chronic Lung Disease: Do you have any lung or breathing problems?

Yes

No

Unknown

Asthma/reactive airway disease

Yes

No

Unknown

Emphysema/Chronic Obstructive Pulmonary Disease (COPD)/Chronic Bronchitis

Yes

No

Unknown

Interstitial lung disease

Yes

No

Unknown

Pulmonary fibrosis

Yes

No

Unknown

Restrictive lung disease

Yes

No

Unknown

Sarcoidosis

Yes

No

Unknown

Cystic Fibrosis

Yes

No

Unknown

Chronic hypoxemic respiratory failure with O2 requirement (Do you use oxygen at home?)

Yes

No

Unknown

Obstructive sleep apnea (OSA)

Yes

No

Unknown

Other chronic lung disease

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Active tuberculosis

Yes

No

Unknown

Cardiovascular (CV) disease: Do you have any heart or blood vessel problems?

Yes

No

Unknown

Hypertension (high blood pressure)

Yes

No

Unknown

Coronary artery disease (heart attack)

Yes

No

Unknown

Heart failure/Congestive heart failure

Yes

No

Unknown

Cerebrovascular accident/Stroke

Yes

No

Unknown

Congenital heart disease (childhood heart problem)

Yes

No

Unknown

Valvular Heart Disease (abnormal heart valve[s] – e.g., aortic stenosis, mitral regurgitation)

Yes

No

Unknown

Arrhythmia (abnormal/irregular heartbeat or rhythm)

Yes

No

Unknown

Other CV disease (e.g. peripheral artery disease, aortic aneurysm, cardiomyopathy, or other heart or vessel diseases specified by the patient)

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Endocrine disorder: Do you have any hormone problems, like diabetes?

Yes

No

Unknown

Diabetes Mellitus (DM)

Yes

No

Unknown

If yes, specify DM Type 1 or 2

Yes

No

Unknown

If yes, what level was your last HgA1c? (Hemoglobin A1c or “A1c”)? ________________ Date (MM/YY)_______________

Unknown

Pre-diabetes

Yes

No

Unknown

If yes, what level was your last HgA1c? (Hemoglobin A1c or “A1c”)? ________________ Date (MM/YY)_______________

Unknown

Other endocrine (hormone) disorder (e.g. pituitary problems, hyperthyroidism, hypothyroidism, Addison’s disease, Cushing’s syndrome

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Renal disease: do you have any kidney problems?

Yes

No

Unknown

Chronic kidney disease/insufficiency

Yes

No

Unknown

End-stage renal disease

Yes

No

Unknown

Dialysis

Yes

No

Unknown

If yes, specify type: hemodialysis (HD) or peritoneal

HD

Peritoneal

Unknown

Other

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Liver disease: do you have any liver problems?

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: _____________________________________________________________________________________________________

Autoimmune disorders: do you have any autoimmune diseases? These include diseases such as…(read below conditions)?

Yes

No

Unknown

Rheumatoid arthritis

Yes

No

Unknown

Systemic lupus

Yes

No

Unknown

Other

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Hematologic disorders: do you have any blood problems?

Yes

No

Unknown

Anemia

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Sickle cell disease

Yes

No

Unknown

Sickle cell trait

Yes

No

Unknown

Bleeding or clotting disorders

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Other hematologic (blood) disorders

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Immunocompromised Condition: do you have any conditions or diseases that make you more prone to infections?

Yes

No

Unknown

HIV infection

Yes

No

Unknown

If yes, what was your last CD4 Count? _______________________ Date (MM/YY)_________________________

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

Leukemia

Yes

No

Unknown

Lymphoma

Yes

No

Unknown

Multiple myeloma

Yes

No

Unknown

Splenectomy/asplenia

Yes

No

Unknown

Other:

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Cancer: have you had, or do you have, cancer?

Yes

No

(skip to next section)

Unknown

(skip to next section)

If yes, what type of cancer? _______________________________________________________________________________________________

What year did were you diagnosed? _________________________


Did your cancer treatment include any of the following? (If yes, specify what years you received treatment)

IV Chemotherapy

Yes

No

Unknown

Year(s): ________________________________

Oral chemotherapy (pills)

Yes

No

Unknown

Year(s): ________________________________

Radiation

Yes

No

Unknown

Year(s): ________________________________

Other: ___________________________________

Yes

No

Unknown

Year(s): ________________________________

Neurologic/neurodevelopmental disorder: do you have any diseases of the brain, spinal cord, or nerves?

Yes

No

Unknown

If Yes, specify: _____________________________________________________________________________________________________

Psychiatric Diagnosis: do you have any mental health problems? (e.g. depression, bipolar disorder, anxiety disorder, schizophrenia)

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. Do you use or depend on any of the following?

Feeding tube Yes No Unknown

Tracheostomy Yes No Unknown

Wheelchair Yes No Unknown

Walker Yes No Unknown

  1. Are you bed-ridden? Yes No


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

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

  3. If currently pregnant or postpartum, have you had or did you have any complications during this pregnancy?

None Gestational diabetes Pre-eclampsia Pregnancy-induced hypertension (PIH) Intrauterine growth restriction (IUGR)

Other, specify: ________________________________________________________________

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

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


  1. Do you have health insurance? Yes No Unknown

If yes, what kind of health insurance do you have? Private Medicare Medicaid Indian Health Service (IHS)

Military (Tricare) Incarcerated Unknown/Did not want to answer


Medication history

The next several questions will ask about medications. First, I would like to know all medications taken during the month before your illness began, and then I will ask about all medications taken during your COVID-19 illness (*up to hospitalization). We are interested in all medications, including prescriptions, inhalers, over the counter medications, vitamins, supplements, and herbs. If you have a list or container of medications, including any inhalers please get that now. Let me know when you’re ready to begin


  1. During the month before your illness began, what types of medications did you take for underlying conditions, including prescriptions, inhalers, over the counter medications, vitamins, supplements, and herbs?

Do you take any medications for high blood pressure, pain, or fever? (If yes, ask questions to fill in table below – example prompting questions and abbreviation definitions are in the SOP)

How about for infections caused by fungus, bacteria, or viruses? (If yes, ask questions to fill in table below)

How about any medications that may weaken your immune system and ability to fight infections? These medications are often used to

treat autoimmune disorders or inflammation. (If yes, ask questions to fill in table below)

Do you use an inhaler? (If yes, ask questions to fill in table below)

Any other medications you may have forgotten? (If yes, ask questions to fill in table below)


Did not take any medications in the month before COVID-19 illness began

Medication Name

Route

Frequency

Continued to take during Illness?


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes No

Unknown


Indication: _______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes No

Unknown


Indication: _______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes No

Unknown


Indication: _______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes No

Unknown


Indication: _______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes No

Unknown


Indication: _______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes No

Unknown


Indication: _______________________________________________________________________________

**If more than 6 medications listed by patient please fill out additional medication section at the end of the questionnaire.


  1. During your COVID-19 illness, did you take any medications other than the medications we covered in the previous section? This includes prescriptions, inhalers, over the counter medications, vitamins, supplements, and herbs. If you were hospitalized for this illness, we only need to know about medications taken up until you were hospitalized. (Prompting questions to fill in table as well as abbreviation definitions can be found in the SOP)

Do you take any medications for pain or fever? (If yes, ask questions to fill in table below)

Did you take any medications for cold or flu symptoms? (If yes, ask questions to fill in table below)

Were you prescribed any medication by a Healthcare Provider? (If yes, ask questions to fill in table below)

Did you take any other medications? (If yes, ask questions to fill in table below)


Did not take any medications during illness (except any mentioned above).

Medication Name

Route

Frequency

Duration


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

______________ days


Indication: _______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

______________ days


Indication: _______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

______________ days


Indication: _______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

______________ days


Indication: _______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

______________ days


Indication: _______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

______________ days


Indication: _______________________________________________________________________________

**If more than 6 medications listed by patient please fill out additional medication section at the end of the questionnaire.


  1. If Chloroquine was listed as a medication taken: What dose of Chloroquine did you take? _______________ unit: ____________ 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


The next several questions will ask about substance use. As a reminder, this information will remain private.

  1. Do you currently use any of the following recreational drugs?

What substance do you use?

(check all that apply)

Around how many times in the month prior to becoming sick did you use?

Did you use while sick with COVID-19?

Marijuana/THC


No Yes, more than usual Yes, the same amount

Yes, but less than usual Unknown

If yes, do you inhale or consume THC/marijuana? (check all that apply)

Inhale Consume

Cocaine


No Yes, more than usual Yes, the same amount

Yes, but less than usual Unknown

Heroin


No Yes, more than usual Yes, the same amount

Yes, but less than usual Unknown

Methamphetamine (”Meth”)


No Yes, more than usual Yes, the same amount

Yes, but less than usual Unknown

Other: __________________


No Yes, more than usual Yes, the same amount

Yes, but less than usual Unknown

Other: __________________


No Yes, more than usual Yes, the same amount

Yes, but less than usual Unknown

Other: __________________


No Yes, more than usual Yes, the same amount

Yes, but less than usual Unknown




Course of Illness

  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)

Name of healthcare facility 1: ____________________________________

Facility 2: _______________________________________

Emergency room

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

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

Name of healthcare facility 1: ____________________________________

Facility 2: _______________________________________

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)

Name of healthcare facility 1: ____________________________________

Facility 2: _______________________________________

Telephone triage line

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

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

Name of healthcare facility 1: ____________________________________

Facility 2: _______________________________________

Telemedicine

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

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

Name of healthcare facility 1: ____________________________________

Facility 2: _______________________________________

Other __________

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

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

Name of healthcare facility 1: ____________________________________

Facility 2: _______________________________________

Unknown




  1. Did you have any imaging such as an X-ray or CT for this illness? Yes No Unknown

  2. Did you have any blood tests done for this illness? Yes No Unknown

  3. Were you hospitalized for this illness? Yes No Unknown

If yes, were you hospitalized because of how unwell you were or for another reason such as isolation (to prevent spread of disease)? Unwell Isolation Other: ______________________________________










Additional Medications (if needed):

MAKE SURE TO CHECK WHETHER THIS IS A MEDICATION TAKEN PRIOR TO ONSET (Q37) OR AFTER SYMPTOM ONSET (Q38)

*fill out this variable only for medications from Q37

^fill out this variable only for medications from Q38

Medication Name

Route

Frequency

Continued to take during Illness?*

Duration^


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes

No

Unknown

__________days

before onset* after^

Indication: ______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes

No

Unknown

__________days

before onset* after^

Indication: ______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes

No

Unknown

__________days

before onset* after^

Indication: ______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes

No

Unknown

__________days

before onset* after^

Indication: ______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes

No

Unknown

__________days

before onset* after^

Indication: ______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes

No

Unknown

__________days

before onset* after^

Indication: ______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes

No

Unknown

__________days

before onset* after^

Indication: ______________________________________________________________________________


PO Injection

Topical Inhaled

Other ______________

QD BID TID QOD

Unknown

Other ________________

Yes

No

Unknown

__________days

before onset* after^

Indication: ______________________________________________________________________________





Shape2 Any additional comments or notes?


This is the end of the case interview. Thank you very much for your time. If you have any questions please feel free to contact the CDPHE COVID-19 helpline at 303-692-2700. If you have questions about this study, please inform them that you are a participant in the Colorado COVID-19 Case Control Study.

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).

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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