Form 0920-0134 Supplemental COVID-2019 Questionnaire

COVID-2019 SUPPLEMENTAL QUESTIONNAIRE

Form Approved

OMB Control No.0920-0134

Exp 03/31/2022

Providing the following information to the Centers for Disease Control and Prevention is required under Title 42 Code of Federal Regulations Section 71.20 and is being collected as part of the public health response to the pandemic of coronavirus disease 2019 (COVID-19). The information will be used by U.S. public health authorities and other international, federal, state, or local agencies for public health purposes.

Instructions for CDC Quarantine Station Staff

• This form is used by CDC staff to collect public health information not captured by the CDC Air Illness or Death Investigation form.

• If there is any risk of COVID-19, ensure traveler is separated by at least 6 feet from others to the extent possible. Traveler should wear a face mask if older than 2 years, and be able to tolerate. Any personnel within 6 feet of traveler should wear recommended PPE as directed by their agency’s Standard Operating Procedures.

• Provide the information collected to the Quarantine Medical Officer (QMO) to inform assessment of the traveler’s infectious status and disposition.

• If referring a traveler for isolation and medical evaluation, provide the information collected to the health department and the health care facility.

• Enter the information collected into the QARS record.

1. Why was traveler referred to the Quarantine Station? (Check all that apply)

_______ Symptomatic

_______ Reported COVID-19 exposure

_______ Reported COVID-19 diagnosis

2. Is traveler currently symptomatic¹? YES_____ NO ______

If yes, complete CDC Air Illness or Death Investigation form and include all symptoms of COVID-19 then continue with #3 if COVID-19 is suspected.

3. Has traveler had contact with a person known to have COVID-19 in the past 14 days? YES ______ NO______

1. If Yes,

1. What was traveler’s relationship to the person(s) with COVID-19 (e.g., friend, colleague, family member, spouse, etc.)?
   __________________________________________________________________________________

2. Did traveler have close contact (within 6 feet/2 meters)? YES ______ NO______

1. If yes, was person with COVID-19 wearing a mask at the time? YES ______ NO______

2. What was the duration of the close contact? _________________

3. If duration was < 15 minutes, were there other high-risk exposures (kissed, got coughed on, etc.)? YES ______ NO______

4. Has traveler even been tested or diagnosed with COVID-19? YES ______ NO______

1. If yes, when was specimen collected? _______/_______/_______ (Day/Month/Year)

• Date is approximate (Check if traveler doesn’t remember exact date)

REMEMBER

PCR/molecular tests and antigen/rapid tests are VIRAL tests. Viral tests check whether a person has COVID-19 at the time the specimen is collected.

Antibody/serology tests check if the person had an infection in the past.

Nose, throat and saliva specimens are used for viral tests.

Blood samples are used for antibody tests.

1. What type of test was done?

Check one:

PCR/molecular ______

Antigen/rapid ______

Antibody/serology ______

Unknown ______

2. Are lab records available for review? YES ______ NO______

If no, and traveler doesn’t know type of test, ask what type of specimen was collected.

Nose or throat or saliva ______

Blood ______

Complete 4B if the COVID-19 test was a viral test and the specimen was collected in the last three weeks.

2. Did the traveler have any symptoms associated with COVID-19 around the time of the positive test? YES ______ NO______

1. What date did their symptoms start? _______/_______/_______ (Day/Month/Year)

2. How long did symptoms last? _____________________________________ (Days)

3. Were they hospitalized?

1. If yes, for how long? __________________________________________

2. Were they in an intensive care unit? YES ______ NO______

4. Have their symptoms improved? YES ______ NO______

5. Did they have a fever (≥100.4 F or 38 C or feel feverish)? YES ______ NO______

1. When did they last have a fever? _______/_______/_______ (Day/Month/Year)

2. When did they last take any fever-reducing medications? ______/______/______

(Day/Month/Year)

1 For current list of COVID-19 symptoms see Symptoms of Coronavirus: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html

This data collection is mandatory. Public reporting burden of this collection of information is estimated to average 5 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 0920-0134.

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