Risk Factor Interview

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

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

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. 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

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 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: ___________________________

20. 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 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. What was the onset date of your first symptom (MM/DD/YYYY): ____/_____/_______ Unknown

22. 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

23. What was the first symptom you experienced? _________________________________________________________

24. 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

25. 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

26. 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: _____________________________________________________________________________________________________

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

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

29. 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

30. Are you bed-ridden? Yes No

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

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

33. 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: ________________________________________________________________

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

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

36. 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

37. 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.

38. 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.

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

Social history

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

41. 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)

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

43. 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.

44. 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

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

If yes, how many days during illness? __________

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

47. 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

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

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

50. 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: ______________________________________________________________________________

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).