0920-1011 2019 nCoV Household Close Contact Investigation

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

H uman Infection with 2019 Novel Coronavirus (nCoV)

Household/Close Contact Investigation Form

Date of Interview (M/D/Y):

Household/Close Contact Information

Last Name: First Name:

Current Street Address:

City: State: Zip: County:

Home phone number: Work phone number:

Mobile phone number: Email address:

Primary language: Translator used for this form? Y N

Interviewer Information

Last Name: First Name:

Affiliation/Organization:

Interview Source

[ ] Contact [ ] Other, specify name: ___________________________________

Relationship to contact

Reason contact unable to be interviewed: [ ] minor [ ] other, specify_________

Has the contact had symptoms consistent with the current PUI criteria? Y N

If yes, then STOP and DO NOT COMPLETE THIS FORM. Contact should be referred for PUI evaluation.

Was this contact exposed to the confirmed 2019-nCoV case listed above? Y N

Date of contact’s last exposure to 2019-nCoV case (M/D/Y) _________

Has the contact had symptoms consistent with the current PUI criteria? Y N

If the date of last exposure to case-patient is >14 days, then STOP and DO NOT COMPLETE THIS FORM.

If the date of last exposure to case-patient is ≤14 days, then COMPLETE THIS FORM.

Demographics

Date of birth (M/D/Y) Age _____ [ ] months [ ] years

Sex M F U.S. Resident Y N Country of Birth (if not U.S.)

Ethnicity:

 Hispanic of Latino  Non-Hispanic or Latino

Race (select all that apply):

 White

 Asian

 Black or African American

 Native Hawaiian or Other Pacific Islander

 American Indian or Alaska Native

Exposures to Case-Patient

Relationship to 2019-nCoV case: _________________

Period of Exposure:

From: Date of symptom onset in 2019-nCoV case-patient m/d/y _______

Through: Last contact with 2019-nCoV case-patient m/d/y _______

Setting: Household Leisure Work School/University Transit Healthcare Other___________

If healthcare setting selected, skip to “Social History” section and complete the “Tracking Form for Asymptomatic Healthcare Personnel Potentially Exposed to nCoV” form

During the period of exposure, did the contact?

	Answer	Estimated frequency (e.g., daily, 2x daily,etc.)	Estimated duration (specify units)
Have face to face contact?	Y N
Have direct physical contact? (e.g., hug, shake hands, etc.)	Y N
Have exposure to the case coughing or sneezing?	Y N
Take an object handed from or handled by the case? (e.g., pen, paper, fork, etc.)	Y N
In the same room as the case?	Y N
Physically within 6 feet of the case?	Y N

Social History

Smoker (tobacco): Current Former No/Unknown If current, how many packs per day? ______

Alcohol: Current Former No/Unknown

Past Medical History

Does the contact have any of the following pre-existing medical conditions currently?

Chronic metabolic disease

Diabetes: Type 1 or Type 2 Y N

Other (specify) Y N

Chronic lung disease

Asthma/Reactive Airway Disease Y N

Emphysema/COPD Y N

Tracheostomy Y N

Active Tuberculosis Y N

Use of supplemental oxygen at home Y N

Other (specify) Y N

Blood disorders

Sickle Cell Anemia Y N

Splenectomy/asplenia Y N

Other (specify) Y N

Immunocompromising conditions

HIV Y N

AIDS or CD4 count<200 Y N

History of hematopoietic stem cell transplant Y N

History of solid organ transplant (specify organ: ) Y N

Cancer in last 12 months (specify: ) Y N

Chemotherapy/Radiation therapy in last 12 months Y N

Primary immunodeficiency Y N

Steroid therapy (for >2 weeks) Y N

Other (specify) Y N

Renal Disease

Chronic kidney disease/Chronic renal insufficiency Y N

End stage renal disease Y N

Dialysis Y N

Other (specify) Y N

Cardiovascular disease

Hypertension Y N

Coronary artery disease Y N

Heart failure/CHF Y N

Cerebrovascular accident/Stroke Y N

Congenital heart disease Y N

Other (specify) Y N

Neuromuscular/Neurologic Disorder

Dementia/Alzheimer’s Disease Y N

Severe developmental delay Y N

Plegias/paralysis Y N

Epilepsy/seizure disorder Y N

Other (specify) Y N

Liver

Alcoholic hepatitis Y N

Chronic liver disease Y N

Cirrhosis/End stage liver disease Y N

Hepatitis B, chronic (HBV) Y N

Hepatitis C, chronic (HCV) Y N

Non-alcoholic fatty liver disease (NAFLD)/NASH Y N

If female, currently pregnant? Y N

Use this space to specify any specific activities that case-patient and contact did together, etc.; specific places the case-patient and 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).