0920-1011 2019 nCoV PUI Form

Emergency Epidemic Investigation Data Collections - Burden Hour Increase 01SEP2020

Appendix 2 2019-nCoV PUI Form (revised)

OMB: 0920-1011

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CDC nCoV ID ___________


Form Approved: OMB: 0920-1011 Exp. 4/23/2020



2019 novel coronavirus (2019-nCoV) patient under investigation (PUI) form

As soon as possible, notify and send completed form to: 1) your local/state health department, and 2) CDC: email ([email protected], subject line: nCoV PUI Form) or fax (770-488-7107). If you have questions, contact the CDC Emergency Operations Center (EOC) at 770-488-7100.

Today’s date__________ State patient ID____________ NNDSS local record ID/Case ID1 _________ State___ County________

Interviewer’s name________________________________ Phone_____________________ Email________________________

Physician’s name _________________________________ Phone_____________________ Pager or Email_________________

Sex M F Age________ yr mo Residency US resident Non-US resident, country_______________________

PUI Criteria

Date of symptom onset_____________________

Does the patient have the following signs and symptoms (check all that apply)?

Fever2 Cough Sore throat Shortness of breath

In the 14 days before symptom onset, did the patient:

Spend time in Wuhan City, China?

Does the patient live in Wuhan City? Y N Unknown

Date traveled to Wuhan City______ Date traveled from Wuhan City______ Date arrived in US______

Y N Unknown

Have close contact3 with a person who is under investigation for 2019-nCoV while that person was ill?

Y N Unknown

Have close contact3 with a laboratory-confirmed 2019-nCoV case while that case was ill?

Y N Unknown

Additional Patient Information

Is the patient a health care worker? Y N Unknown

Have history of being in a healthcare facility (as a patient, worker, or visitor) in Wuhan City, China? Y N Unknown

Is patient a member of a cluster of patients with severe acute respiratory illness (e.g., fever and pneumonia requiring hospitalization) of unknown etiology in which nCoV is being evaluated? Y N Unknown

Does the patient have these additional signs and symptoms (check all that apply)?

Chills Headache Muscle aches Vomiting Abdominal pain Diarrhea Other, Specify_______________

Diagnosis (select all that apply): Pneumonia (clinical or radiologic) Y N Acute respiratory distress syndrome Y N

Comorbid conditions (check all that apply): None Unknown Pregnancy Diabetes Cardiac disease Hypertension

Chronic pulmonary disease Chronic kidney disease Chronic liver disease Immunocompromised Other, specify

Is/was the patient: Hospitalized? Y, admit date_____________ N Admitted to ICU? Y N

Intubated? Y N On ECMO? Y N Patient died? Y N

Does the patient have another diagnosis/etiology for their respiratory illness? Y, Specify______________ N Unknown

Respiratory diagnostic results

Test

Pos

Neg

Pending

Not done

Influenza rapid Ag A B

Influenza PCR A B

RSV

H. metapneumovirus

Parainfluenza (1-4)

Adenovirus

Rhinovirus/enterovirus

Coronavirus (OC43, 229E, HKU1, NL63)

M. pneumoniae

C. pneumoniae

Other, Specify_________

Specimens for 2019-nCoV testing

Specimen type

Specimen ID

Date collected

Sent to CDC?

NP swab



OP swab



Sputum



BAL fluid



Tracheal aspirate



Stool



Urine



Serum



Other, specify____



Other, specify____



1 For NNDSS reporters, use GenV2 or NETSS patient identifier.

2 Fever may not be present in some patients, such as those who are very young, elderly, immunosuppressed, or taking certain medications. Clinical judgement should be used to guide testing of patients in such situations

3 Close contact is defined as: a) being within approximately 6 feet (2 meters) or within the room or care area for a prolonged period of time (e.g., healthcare personnel, household members) while not wearing recommended personal protective equipment (i.e., gowns, gloves, respirator, eye protection); or b) having direct contact with infectious secretions (e.g., being coughed on) while not wearing recommended personal protective equipment. Data to inform the definition of close contact are limited. At this time, brief interactions, such as walking by a person, are considered low risk and do not constitute close contact.

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/msword
AuthorAbedi, Glen R. (CDC/DDID/NCIRD/DVD) (CTR)
File Modified0000-00-00
File Created2021-01-13

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