COVID-19 Case Investigation Worksheet

Status: Original and derived artifacts are available for this document.

Download: xlsx | pdf | html

Ship name:
Current voyage #:
Current voyage start date (MM/DD/YYYY):
Current voyage end date (MM/DD/YYYY):
This worksheet is to be used for 1) lab-confirmed COVID-19 cases, and 2) CLI cases with
Demographic

Case ID#

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

Case Initials
(e.g., Jane
Doe = JD)

Traveler type
(crew or
passenger)

Date of Birth
(MM/DD/YYYY)

Country of
Residence

Embarkation
Date
(MM/DD/YYYY)

VID-19 cases, and 2) CLI cases with negative COVID-19 test results without a positive test result for another respiratory pathogen (i.e., in
Vaccine History
Disembarkation
Vax Dose #1 Date
Date
Is person fully vaccinated?
(MM/DD/YYYY)
(MM/DD/YYYY)

Vax Dose #1
Manufacturer

Vax Dose #2 Date
(MM/DD/YYYY)

Vax Dose #2
Manufacturer

spiratory pathogen (i.e., influenza A or B, RSV, Streptococcal pharyngitis, Legionella, etc.).
Demographic and Medical Information
Medical
Sought medical
If yes, date seen by
attention (i.e.,
Is this a vaccine breakthrough
Is person symptomatic?
case?
Does person have risk factors for severe illness?
medical provider
medical center, in(MM/DD/YYYY)
cabin)?

*CDC close contact definition

on

Test results (fou
Identified as a close
contact* to a another
case?

If yes (and not fully
vaccinated), date
began quarantine
(MM/DD/YYYY)

Type of testing
received (#1)

Date specimen
Testing result
collected (#1)
(#1)
(MM/DD/YYYY)

This worksheet is to be used for 1) lab-co
Test results (four most recent tests, including positive and negative results)

Type of testing
received (#2)

Date specimen
Testing result
collected (#2)
(#2)
(MM/DD/YYYY)

Type of testing
received (#3)

Date specimen
Testing result
collected (#3)
(#3)
(MM/DD/YYYY)

rksheet is to be used for 1) lab-confirmed COVID-19 cases, and 2) CLI cases with negative COVID-19 test results without a positive test r

Cre

Type of testing
received (#4)

Date specimen
Cabin #
Testing result
collected (#4)
(at time of
(#4)
(MM/DD/YYYY)
diagnosis)

Any cabin
mates
(at time of
diagnosis)?

Any shared
bathroom
(at time of
diagnosis)?

D-19 test results without a positive test result for another respiratory pathogen (i.e., influenza A or B, RSV, Streptococcal pharyngitis, Le
Exposure I
Crew
Ship department (i.e.,
galley/dining room,
salon, cook, security,
etc.)

Job location(s)

Participated in shore
leave/trips/excursions
w/in past 14 days?

If yes, which
seaport(s)?

Date(s) of
excursions
(MM/DD/YYYY)

RSV, Streptococcal pharyngitis, Legionella, etc.).
Exposure Information
Passenger

Cabin #

Any cabin
mates
(at time of
diagnosis)?

Any cabin
mates also
cases?

If Yes, initials
Initials of travel
of cabin mate
companion case(s)
(e.g., John
(e.g., John Doe = JD)
Doe = JD)

If Yes, Initials of travel
companion case(s)
(e.g., John Doe = JD)

*CDC close contact definition

Close contacts
Participated in voyagerelated shore
trips/excursions w/in
past 14 days?

If yes, which
seaport(s)?

Date(s) of
excursions
(MM/DD/YYYY)

# of crew
close
contacts*
identified

# of
passenger
close
contacts*
identified