App 2_Data Collection Forms

Appendix 2. Data Collection Forms.pdf

Emergency Epidemic Investigation Data Collections- -Expedited Review (Y3Q4)

App 2_Data Collection Forms

OMB: 0920-1011

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-1011 can be found here:

2022-10-07 - Revision of a currently approved collection

Document [pdf]

Download: pdf | pdf

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

Human Infection with 2019-Novel Coronavirus (2019-nCoV)
Case Report Form
State/local ID: _________ CDC ID:_____________ Dash sticker:
_________
:_____________________
Household ID: _________Cluster
ID:______________

____________________

Interviewer Information
Date interview completed: / /
(MM/DD/YYYY)
Date reported to health department: / / (MM/DD/YYYY)
Interviewer Name:________________________________________________ State/Local Health Department___________________________________
Who is providing information for this form?
Case-patient
Other, specify name: ______________________________ Relationship to case patient: ____________________________________
Case-patient primary language: _________________________ Was this form administered via a translator? □ Yes □ No

Case-Patient Information
Last Name: _________________________________________
First Name: ______________________________________________
Current Address:
City:
State:
Zip:
_________________________________
_______________
______________________
______________________
Phone No. 1: _______________________
Other point of contact
Other point of contact Phone: Relationship to case patient:
name:_________
____________________________________
Phone No. 2:________________________
__________________
Date reported to health department: / / (MM/DD/YYYY)
At the time of this report, is this patient a 2019-nCoV laboratory-confirmed case?
Yes
No

Demographic information
1. Date of birth:
/
/
(MM/DD/YYYY)
2. Age: _______
years
months
3. Current residence: Country: _________ State:______________County___________City______________
4. Living situation at time of illness:
Private residence
Military base
Shelter
Nursing home/long-term healthcare facility
School
dormitory
Homeless
Detention facility
Other: _______________
5. Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
6. Race (Select all that apply):
White
Asian
American Indian/Alaska Native
Black or African American
Native Hawaiian/Other
Pacific Islander
7. Sex:
Male
Female
8. Is the patient a healthcare worker?
Yes
No
Unknown
9. Occupation

Clinical Presentation and Course
10.Date of first symptom onset __/___/_____ (MM/DD/YYYY)
11.Does the patient still have symptoms?
Yes
No
Unknown
12.When did the patient feel back to normal?
/
/
(MM/DD/YYYY)
13.During this illness, did the patient experience any of the following?
Symptom
Fever >100.4F (38C)
Highest temp________ °F
Subjective fever (felt feverish)
Chills
Cough (new onset or worsening of
chronic cough)
Dry
Productive
Bloody sputum (hemoptysis)
Sore throat
Wheezing
Shortness of breath (dyspnea)
Swollen lymph nodes (lymphadenopathy)
Apnea
Runny nose (rhinorrhea)
Eye redness (conjunctivitis)
Ear pain
Rash
Abdominal pain

Symptom Present?
Yes
No

Date of Onset (MM/DD/YY)

Duration (no. of days)

Unk

Yes
Yes
Yes

No
No
No

Unk
Unk
Unk

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No
No
No

Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk

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).

Human Infection with 2019-Novel Coronavirus (2019-nCoV)
Case Report Form
Nausea
Vomiting
Diarrhea (>3 loose stools/day)
Chest Pain
Muscle aches (myalgia)
Headache
Dizziness
Fatigue
Altered Mental Status
Seizures
Other, specify:
Other, specify:

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No
No

Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk

14.Did the patient seek medical care for this illness? Yes
No
Unk
If, yes which type of facility: (Check all that apply)
Outpatient clinic
Urgent Care Emergency department
15.Was the patient hospitalized for the illness? (if yes, complete hospital form)
Yes
No
Unknown
16.Is the patient still hospitalized for this illness?
Yes
No
Unknown
17.Did the patient have an abnormal chest x-ray? Yes
No
Unk Not performed
18.Did the patient receive supplemental oxygen? Yes
No
Unk
19.Was the patient admitted to the intensive care unit (ICU)? Yes
No
20.Did the patient receive mechanical ventilation? Yes
No
Unk
21.Was the patient on extra corporeal membranous oxygen (ECMO)? Yes
No
Unk
22.Patient outcome due to illness: Survived
Died
Unk

Hospital

Unk

Medical History
23.Does the patient have any of the following chronic medical conditions? Please specify ALL conditions that qualify.
Chronic Lung Disease
Asthma/reactive airway disease
Yes
No
Unknown
Other chronic lung disease
Yes
No
Unknown (If YES, specify)
Diabetes Mellitus
Diabetes Mellitus Type 1
Yes
No
Unknown
Diabetes Mellitus Type 2
Yes
No
Unknown
Hypertension
Yes
No
Unknown
Chronic heart or cardiovascular disease
Yes
No
Unknown (If YES, specify)
Chronic kidney disease
Yes
No
Unknown (If YES, specify)
Liver disease
Yes
No
Unknown (If YES, specify)
Non-cancer immunosuppressive condition or
Yes
No
Unknown (If YES, specify)
treatment
Cancer chemotherapy in past 12 months
Yes
No
Neurologic/neurodevelopmental disorder
Yes
No
Other, specify:
Yes
No
24.Was patient pregnant at illness onset?
Yes, weeks pregnant at onset
No
25.Was patient ≤6 weeks postpartum at illness onset?
Yes, postpartum (delivery date) ___/___/___ (MM/DD/YYYY)

Unknown (If YES, specify)
Unknown (If YES, specify)
Unknown (If YES, specify)
Unknown
No

Unknown

26.Has the patient ever smoked? Yes
No
Unknown
27.Does the patient currently smoke? Yes
No
Unknown
28.Does the patient currently smoke e-cigarettes? Yes
No
Unknown
2019-nCoV Laboratory Testing
(For each specimen type, please report earliest positive specimen, or earliest collected if all negative)
Specimen Type
NP Swab
OP Swab
Sputum
Bronchoalveolar lavage (BAL) fluid
Tracheal fluid
Stool
Urine
Serum

Date of Collection
__/__/____ (MM/DD/YYYY)
__/__/____ (MM/DD/YYYY)
__/__/____ (MM/DD/YYYY)
__/__/____ (MM/DD/YYYY)
__/__/____ (MM/DD/YYYY)
__/__/____ (MM/DD/YYYY)
__/__/____ (MM/DD/YYYY)
__/__/____ (MM/DD/YYYY)

Test Result
Positive
Positive
Positive
Positive
Positive
Positive
Positive
Positive

Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative

Indeterminate
Indeterminate
Indeterminate
Indeterminate
Indeterminate
Indeterminate
Indeterminate
Indeterminate

Pending
Pending
Pending
Pending
Pending
Pending
Pending
Pending

Human Infection with 2019-Novel Coronavirus (2019-nCoV)
Case Report Form
Other, specify____

__/__/____ (MM/DD/YYYY)

Positive

Negative

Indeterminate

Pending

Exposure

29. In the 14 DAYS prior to illness, did the case-patient travel outside of the United States? Yes No Unknown
If yes, city___________ state/province _________ country______________ Dates of travel: (MM/DD/YYYY) ___/___/___ - ___/___/___
If yes, city___________ state/province _________ country______________ Dates of travel: (MM/DD/YYYY) ___/___/___ - ___/___/___
If yes, city___________ state/province _________ country______________ Dates of travel: (MM/DD/YYYY) ___/___/___ - ___/___/___
30. In the 14 DAYS prior to illness, did the case-patient travel outside of their state of residence? Yes No Unknown
If yes, city___________ county _________ state___________ Dates of travel: (MM/DD/YYYY) ___/___/___ - ___/___/___
If yes, city___________ county _________ state___________ Dates of travel: (MM/DD/YYYY) ___/___/___ - ___/___/___
If yes, city___________ county _________ state___________ Dates of travel: (MM/DD/YYYY) ___/___/___ - ___/___/___
31. In the 14 DAYS prior to illness, did the patient:

Have close contact with a confirmed 2019-nCoV case-patient?
Yes
Have close contact with any household members, friends, acquaintances, or co-workers who had symptoms
Yes
like the case-patient’s?
Visit a live animal market? If yes, specify __________________________________
Yes
Work or volunteer in a healthcare setting?
Yes
Visit a healthcare setting?
Yes
32. Was this patient under active or passive monitoring following exposure to a confirmed 2019-nCoV case-patient?
Yes
No
Unknown

No
No

Unknown
Unknown

No
No
No

Unknown
Unknown
Unknown

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

Internal use
CDC nCoV ID ___________

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?
☐ Y ☐ N ☐ Unknown
Does the patient live in Wuhan City? ☐ Y ☐ N ☐ Unknown
Date traveled to Wuhan City______ Date traveled from Wuhan City______ Date arrived in US______
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
Influenza rapid Ag ☐ A ☐ B

Pos

☐
Influenza PCR ☐ A ☐ B
☐
RSV
☐
H. metapneumovirus
☐
Parainfluenza (1-4)
☐
Adenovirus
☐
Specimens for 2019-nCoV testing
Specimen type
NP swab
OP swab
Sputum
BAL fluid
Tracheal aspirate
1
2
3

Specimen ID

Neg

☐
☐
☐
☐
☐
☐

Pending

☐
☐
☐
☐
☐
☐

Date collected

Not done

☐
☐
☐
☐
☐
☐

Sent to CDC?
☐
☐
☐
☐
☐

Test
Rhinovirus/enterovirus

Coronavirus (OC43, 229E,
HKU1, NL63)
M. pneumoniae
C. pneumoniae
Other, Specify_________
Specimen type
Stool
Urine
Serum
Other, specify____
Other, specify____

Pos

Neg

Pending

Not done

☐
☐
☐

☐
☐

Specimen ID

☐
☐

Date collected

☐
☐

Sent to CDC?
☐
☐
☐
☐
☐

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

CDC 2019-nCoV ID:

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

……………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……………………

Human Infection with 2019 Novel Coronavirus
Person Under Investigation (PUI) and Case Report Form
Reporting jurisdiction:
Reporting health department:
Contact ID a:
a.

______________
______________
______________

Case state/local ID:
CDC 2019-nCoV ID:
NNDSS loc. rec. ID/Case ID b:

______________
______________
______________

Only complete if case-patient is a known contact of prior source case-patient. Assign Contact ID using CDC 2019-nCoV ID and sequential contact ID, e.g., Confirmed case CA102034567 has contacts CA102034567 -01 and
CA102034567 -02. bFor NNDSS reporters, use GenV2 or NETSS patient identifier.

Interviewer information
Name of interviewer: Last ______________________________ First______________________________________
Affiliation/Organization: _______________________________ Telephone ________________ Email ______________________________

Basic information
What is the current status of this person?
PUI, testing pending
PUI, tested negative
Presumptive case (positive local test),
confirmatory testing pending
Presumptive case (positive local test),
confirmatory tested negative
Laboratory-confirmed case
Probable case
Report date of PUI to CDC (MM/DD/YYYY):
____/_____/_______
Report date of case to CDC (MM/DD/YYYY):
____/_____/_______
County of residence: ___________________
State of residence: ___________________

Ethnicity:
Hispanic/Latino
Non-Hispanic/
Latino
Not specified
Sex:
Male
Female
Unknown
Other

Date of first positive specimen
collection (MM/DD/YYYY):
____/_____/_______
Unknown
N/A
Did the patient develop pneumonia?
Yes
Unknown
No
Did the patient have acute
respiratory distress syndrome?
Yes
Unknown
No
Did the patient have another
diagnosis/etiology for their illness?
Yes
Unknown
No

Was the patient hospitalized?
Yes
No
Unknown
If yes, admission date 1
___/___/___ (MM/DD/YYYY)
If yes, discharge date 1
__/___/____ (MM/DD/YYYY)
Was the patient admitted to an intensive
care unit (ICU)?
Yes
No
Unknown
Did the patient receive mechanical
ventilation (MV)/intubation?
Yes
No
Unknown
If yes, total days with MV (days)
_______________

Did the patient receive ECMO?
Race (check all that apply):
Did the patient have an abnormal
Yes
No
Unknown
Asian
American Indian/Alaska Native
chest X-ray?
Black
Native Hawaiian/Other Pacific Islander
Yes
Unknown
Did the patient die as a result of this illness?
White
Unknown
No
Yes
No
Unknown
Other, specify: _________________
Date of death (MM/DD/YYYY):
Date of birth (MM/DD/YYYY): ____/_____/_______
____/_____/_______
Age: ____________
Unknown date of death
Age units(yr/mo/day): ________________
Symptoms present
If symptomatic, onset date
If symptomatic, date of symptom resolution (MM/DD/YYYY):
during course of illness:
(MM/DD/YYYY):
____/_____/_____
Symptomatic
____/_____/_______
Still symptomatic
Unknown symptom status
Asymptomatic
Unknown
Symptoms resolved, unknown date
Unknown
Is the patient a health care worker in the United States?
Yes
No
Unknown
Does the patient have a history of being in a healthcare facility (as a patient, worker or visitor) in China?
Yes
No
Unknown
In the 14 days prior to illness onset, did the patient have any of the following exposures (check all that apply):
Travel to Wuhan
Community contact with another
Exposure to a cluster of patients with severe acute lower
Travel to Hubei
lab-confirmed COVID-19 case-patient
respiratory distress of unknown etiology
Travel to mainland China
Any healthcare contact with another
Other, specify:____________________
Travel to other non-US country
lab-confirmed COVID-19 case-patient
Unknown
specify:_____________________
Patient
Visitor
HCW
Household contact with another labAnimal exposure
confirmed COVID-19 case-patient
If the patient had contact with another COVID-19 case, was this person a U.S. case?
Yes, nCoV ID of source case: _______________
No
Unknown
N/A
Under what process was the PUI or case first identified? (check all that apply):
Clinical evaluation leading to PUI determination
Contact tracing of case patient
Routine surveillance
EpiX notification of travelers; if checked, DGMQID_______________
Unknown
Other, specify:_________________

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).

CDC 2019-nCoV ID:

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

Human Infection with 2019 Novel Coronavirus
Person Under Investigation (PUI) and Case Report Form
Symptoms, clinical course, past medical history and social history
Collected from (check all that apply):

Patient interview

Medical record review

During this illness, did the patient experience any of the following symptoms?
Fever >100.4F (38C)c
Subjective fever (felt feverish)
Chills
Muscle aches (myalgia)
Runny nose (rhinorrhea)
Sore throat
Cough (new onset or worsening of chronic cough)
Shortness of breath (dyspnea)
Nausea or vomiting
Headache
Abdominal pain
Diarrhea (≥3 loose/looser than normal stools/24hr period)
Other, specify:_____________________________________________
Pre-existing medical conditions?
Chronic Lung Disease (asthma/emphysema/COPD)
Diabetes Mellitus
Cardiovascular disease
Chronic Renal disease
Chronic Liver disease
Immunocompromised Condition
Neurologic/neurodevelopmental/intellectual
disability
Other chronic diseases
If female, currently pregnant
Current smoker
Former smoker
Respiratory Diagnostic Testing
Test

Pos

Neg

Pend.

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:_________
Additional State/local Specimen IDs: ______________

Symptom Present?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk
Unk

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No

Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown

Yes
Yes
Yes
Yes

No
No
No
No

Unknown
Unknown
Unknown
Unknown

Not
done

______________

Unknown

(If YES, specify)
(If YES, specify)

Specimens for COVID-19 Testing
Specimen
Specimen
Date
Type
ID
Collected
NP Swab
OP Swab
Sputum
Other,
Specify:
_________

______________

State Lab
Tested

______________

State Lab
Result

Sent to
CDC

CDC Lab
Result

______________

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).
2

Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

Human Infection with 2019 Novel Coronavirus (nCoV)
Household Contact Questionnaire V1.5 rev 3/24/2020
(Household Transmission Investigation)

State: WI
Household ID: WI-__________
Study ID: WI-_______________

This questionnaire is to be administered to each household member (excluding the index patient).
Interview Information
1. Date of Interview:
/
/
(MM/DD/YYYY)
2. Name of Interviewer: _________________________________________
3. Person completing the interview:
Self
Parent/guardian: ______________________________
Other: ___________________________________________________
Household Member Information
4. Household member’s name: First:_____________________________ Last:___________________________
5. Date of birth:
/
/
(MM/DD/YYYY)
6. Age: _______
years
months
days
7. Ethnicity:
8. Race:

Hispanic/Latino
Non-Hispanic/Latino
Not Specified
White
Black
Asian
Am Indian/Alaska Nat
Nat Hawaiian/Other PI
Other, specify:___________

9. Sex:
Male
Female
10. What is your relationship to [insert name of index patient]?
Spouse
Child
Parent
Grandparent

Sibling

Employee

Unknown

Other _____________

11. What is the highest level of education you have completed?
Less than high school
High school diploma/GED
Some college credit, no degree
Technical degree/Associate’s degree
Bachelor’s degree (i.e., B.A., B.S.)
Master’s degree (i.e., MBA)
Doctorate or professional degree
12. What is your occupation? ____________________________________________________
SARS-CoV-2 testing for household contacts
13. Have you been tested for coronavirus?
Yes
No
If yes, please complete the following information:
a. Date of specimen collection_______________________________(MM/DD/YYYY)
b. Result of test:
Positive
Negative
Pending
Don’t know/other ________________
c. Date of test result_______________________________(MM/DD/YYYY)
d. Were you experiencing symptoms when you were tested?
Yes
No
i. Describe:_______________________________________________________________
e. Date of symptom onset: _____________________________(MM/DD/YYYY)
Notes:________________________________________________________________________________
Past Medical History
14. Please provide pre-existing medical conditions (complete regardless of age):

Version 1.4 March 24, 2020
1
Public reporting burden of this collection of information is estimated to average 10 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).

Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

Human Infection with 2019 Novel Coronavirus (nCoV)
Household Contact Questionnaire V1.5 rev 3/24/2020
(Household Transmission Investigation)

State: WI
Household ID: WI-__________
Study ID: WI-_______________

Asthma/reactive airway disease
Emphysema/COPD
Active tuberculosis
Any other chronic lung diseases
Diabetes Mellitus
Hypertension (high blood pressure)
Coronary artery disease/heart attack
Congestive heart failure
Stroke
Congenital heart disease
Any other heart diseases
Any kidney disorders? If YES, answer the
following:
End-stage renal disease/dialysis
Renal insufficiency
Other kidney diseases
Any liver disorders? If YES, answer the
following:
Alcoholic liver disease
Cirrhosis/End stage liver disease
Chronic hepatitis B
Chronic hepatitis C
Non-alcoholic fatty liver disease
(NAFLD)/NASH
Other chronic liver diseases
HIV infection. If YES, answer the
following:
AIDS or CD4 count currently <200
Ever receive a transplant? If YES, answer
the following:
Solid organ transplant
Stem cell transplant (e.g., bone
marrow transplant)
Cancer: current/in treatment or
diagnosed in last 12 months
Immunosuppressive therapy/medications

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No
No

Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown

Yes
Yes
Yes
Yes

No
No
No
No

Unknown
Unknown
Unknown
Unknown

Yes
Yes
Yes
Yes
Yes

No
No
No
No
No

Unknown
Unknown
Unknown
Unknown
Unknown

Yes
Yes

No
No

Unknown
Unknown

Yes
Yes

No
No

Unknown
Unknown

Other immunosuppressive conditions
Any other chronic diseases
Developmental or neurologic disorder. If
YES, answer the following:

If YES, on treatment:
If YES, specify:

Yes

Unknown

If YES, specify:

Yes

Unknown

If YES, date:
If YES, date:

Yes

Unknown

If YES, specify:___________________

Yes

Unknown

Yes
Yes
Yes

No
No
No

If YES, specify:___________________
For what condition: _______________________
Unknown
If YES, specify:___________________
Unknown
If YES, specify:
Unknown
If YES, specify:

Version 1.4 March 24, 2020
2
Public reporting burden of this collection of information is estimated to average 10 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).

Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

Human Infection with 2019 Novel Coronavirus (nCoV)
Household Contact Questionnaire V1.5 rev 3/24/2020
(Household Transmission Investigation)

State: WI
Household ID: WI-__________
Study ID: WI-_______________

Chromosomal or genetic abnormality
Cerebral palsy
Epilepsy
Any other development or neurologic
Disorder
Any other medical conditions as a child
Were you born premature?
15.
16.
17.
18.

Yes
Yes
Yes

No
No
No

Unknown
Unknown
Unknown

If YES, specify:___________________________

Yes
Yes

No
No

Unknown
Unknown

If YES, specify:
If yes, gestation at birth:____________wks

[If female] Are you currently pregnant?
[If female] Are you postpartum (≤6 weeks postpartum)?
[If female] Are you breastfeeding?
[If child <3 years] Is your child being breastfed?

Yes
Yes
Yes
Yes

If YES, specify:___________________________

No
No
No
No

Unknown
Unknown
Unknown
Unknown

N/A
N/A
N/A
N/A

Smoking/Vaping
19. Do you currently smoke tobacco on a daily basis, less than daily, or not at all?
Daily
Less than daily
Not at all
Unknown
20. [If not a daily smoker] In the past, have you smoked tobacco on a daily basis, less than daily, or not at all?
Daily
Less than daily
Not at all
Unknown
21. Do you currently vape or use electronic cigarettes on a daily basis, less than daily, or not at all?
Daily
Less than daily
Not at all
Unknown
Symptoms Prior to Index Case’s Onset
Note to interviewer: record symptom onset date of the index patient from household questionnaire cover sheet. Ask the
interviewee to get a calendar or personal diary. ___/____/____ (MM/DD/YYYY)
22. Did you experience any symptoms of a respiratory illness in the 2 weeks prior to [insert name of index patient]
becoming ill?
Yes
No
Unknown
Exposures Outside of the Household
Note to interviewer: remind the interviewee to consult a calendar or diary for the following questions.
Date of index patient symptom onset: ___/____/____(MM/DD/YYYY)
14 days prior to index patient’s symptom onset: ___/____/____ (MM/DD/YYYY)
23. Since [14 days PRIOR to the index patient’s symptom onset]…
Exposure
Answer
…have you traveled (internationally or within the U.S., or
Yes: with index patient
on a cruise)?
No
Unknown
…attend a mass gathering (e.g., religious event, wedding,
party, dance, concert, banquet, festival, sports event, or
other events)?

Yes: with index patient
No
Unknown

Yes: w/o index patient
Yes: w/o index patient

Version 1.4 March 24, 2020
3
Public reporting burden of this collection of information is estimated to average 10 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).

Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

Human Infection with 2019 Novel Coronavirus (nCoV)
Household Contact Questionnaire V1.5 rev 3/24/2020
(Household Transmission Investigation)

State: WI
Household ID: WI-__________
Study ID: WI-_______________

…have close contact (e.g. caring for, speaking with,
touching, physically within 6 feet) with any suspected or
known COVID-19 case outside of the household?
…work in a healthcare setting?

…visit a healthcare setting (e.g. visit someone or have an
appointment -- at a hospital, ED, outpatient clinic, dental
clinic, long-term care facility)?
…attend/work at a daycare?

Yes: with index patient
No
Unknown

Yes: w/o index patient

Yes
No
Unknown
If yes, what types of healthcare settings:
 Hospital
 Outpatient Clinic
 Emergency Dept
 Dental Clinic
 Dialysis Center
 ICU
 Long-term care facility
__________
 Other, specify:
What type of job do you have at the healthcare setting?
 Admin staff
 Nurse/Nurse tech
 Doctor
 EMS
 Other, specify:
___________
Yes
No
Unknown

…attend/work at a school?

Yes

Unknown

Yes

Unknown

Symptoms After the Index Case’s Onset

Note to interviewer: record symptom onset date of the index patient from household questionnaire. Ask the interviewee
to get a calendar or personal diary. ___/____/____ (MM/DD/YYYY)
24. Since ____/____/____, when [the index case] first became
symptomatic, have you experienced any of the following
symptoms?
Fever >100.4F (38C)c
Subjective fever (felt feverish)
Chills
Muscle aches (myalgia)
Runny nose (rhinorrhea)
Sore throat
Cough (new onset or worsening of chronic cough)

Symptom Present?
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No

Unk
Unk
Unk
Unk
Unk
Unk
Unk

Version 1.4 March 24, 2020
4
Public reporting burden of this collection of information is estimated to average 10 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).

Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

Human Infection with 2019 Novel Coronavirus (nCoV)
Household Contact Questionnaire V1.5 rev 3/24/2020
(Household Transmission Investigation)

State: WI
Household ID: WI-__________
Study ID: WI-_______________

Shortness of breath (dyspnea)
Nausea/Vomiting
Headache
Abdominal pain
Diarrhea (≥3 loose/looser than normal stools/24hr period)
Other, specify:

Yes
Yes
Yes
Yes
Yes

No
No
No
No
No

Unk
Unk
Unk
Unk
Unk

25. What date did you first become symptomatic?
___ / __ /_
__ (MM/DD/YYYY)
26. Are you currently experiencing any symptoms of a respiratory illness, such as fever, cough, or shortness of breath?
(Note: Flag any symptomatic household members for workflow planning and offer of self-nasal swab during visit)
Yes
No
Unknown
Exposures to the Index Patient
Note to interviewer: record symptom onset date of the index patient from household questionnaire. Ask the interviewee
to get a calendar or personal diary. ___/____/____ (MM/DD/YYYY)
27. Since [index case]’s symptoms started on [date of symptom onset of the index patient], did you …….?
Exposure
Answer
…spend more than 10 minutes within 6 feet of the index
Yes
No
Unknown
patient?
…have face to face contact with the index patient (i.e.,
Yes
No
Unknown
within about 2 feet)?
…spend any time within 6 feet of the index patient while
Yes
No
Unknown
he/she was coughing or sneezing?
…shake hands with the index patient?
…hug the index patient?
…kiss the index patient?
…take an object handed from or handled by the index
patient? (e.g., pen, paper, food, utensil, etc.)
…sleep in the same bedroom as the index patient?
…sleep in the same bed as the index patient?
…share a bathroom with the index patient?
…prepare food with the index patient?
…share meals with the index patient?
…eat from the same plate as the index patient?

Yes
Yes
Yes
Yes

No
No
No
No

Unknown
Unknown
Unknown
Unknown

Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No

Unknown
Unknown
Unknown
Unknown
Unknown
Unknown

Version 1.4 March 24, 2020
5
Public reporting burden of this collection of information is estimated to average 10 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).

Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

Human Infection with 2019 Novel Coronavirus (nCoV)
Household Contact Questionnaire V1.5 rev 3/24/2020
(Household Transmission Investigation)

State: WI
Household ID: WI-__________
Study ID: WI-_______________

Exposure
…share a utensil with the index patient?
…share a drinking cup/glass with the index patient?
…travel in the same vehicle (car, bus, airplane), sitting
within 6 feet of the index patient?

Yes

Answer
No
Unknown

Yes
Yes

No
No

28. Did you serve as primary caretaker for the index patient while he/she was ill?

Unknown
Unknown
Yes

Unknown

29. When was your last exposure (include any exposures described above) to [name of the index patient]?
___ / __ /_
__ (MM/DD/YYYY)
Ongoing exposure
30. How many days have you spent in the household since [date of symptom onset of index patient]? ____________
31. How many nights have you spent in the household since [date of symptom onset of index patient]? ___________

Version 1.4 March 24, 2020
6
Public reporting burden of this collection of information is estimated to average 10 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).

Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

Human Infection with 2019 Novel Coronavirus (nCoV)
Household Questionnaire V1.4 rev 3/23/2020
(Household Transmission Investigation)

State: ____WI________
Household ID: __WI-_________

HOUSEHOLD QUESTIONNAIRE COVER SHEET
-

If there are multiple confirmed COVID-19 cases in the household at baseline, identify the case with the
earliest symptom onset as the index patient.

Index case information (fill out ahead of time from PUI/CRF and verify at time of questionnaire administration)
1. Index patient’s name: First: ________________________ Last: ______________________
2. Phone number: __________________________________
3. Address: ___________________________________________________________________
4. Index patient’s study ID: ___________
5. Index patient’s date of birth: ____/_____/_______ (MM/DD/YYYY)
6. Date of symptom onset of the index patient:
/
/
__(MM/DD/YYYY)
7. Date of specimen collection of index patient (first positive test): ____/____/________ (MM/DD/YYYY)
8. Date index patient received test result: __ /____/____
(MM/DD/YYYY)
Household member(s) (fill out ahead of time and verify/complete at time of questionnaire)
Name (first last)

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Version 1.3 March 23, 2020

Study ID

Relationship
to case

Age
(yrs)

Sex

DOB

Phone number

Public reporting burden of this collection of information is estimated to average 10 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).

Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

Human Infection with 2019 Novel Coronavirus (nCoV)
Household Questionnaire V1.4 rev 3/23/2020
(Household Transmission Investigation)

State: ____WI________
Household ID: __WI-_________

HOUSEHOLD QUESTIONNAIRE

Note: This questionnaire is to be administered to each household at enrollment. If possible, the head of household
should provide information for questionnaire.
Interview information
1. Date of Interview: MM / DD / YYYY
2. Name of Interviewer: _________________________________________
________
3. Name of household member providing information for interview: _________
Head of household?  Yes  No If no, relationship to head of household: ________________________
4. Location of the interview:
 At the household
 Over the phone
 Other, specify: ____________________________________________
Describing the household
5. Location of the household:
County: __________________________ State: ___________________ ZIP Code: __________________
6. Confirm the number of household members from the cover sheet: __________persons
Note to interviewer: Include resident family members, live-in staff, and long-term visitors.
7. What is the highest level of education completed by the head of the household?
Less than high school
High school diploma/GED
Some college credit, no degree
Technical degree/Associate’s degree
Bachelor’s degree (i.e., B.A., B.S.)
Master’s degree (i.e., MBA)
Doctorate or professional degree
8. What is the occupation of the head of the household? _________________________________________
9. Do you live in a single-family home or multi-unit housing (like an apartment)?
 Single-family home
 Multi-unit housing
 Other (specify):_________________________
10. Do you own or rent your home?
11.
12.
13.
14.

 Own

 Rent

What is the approximate size of the residence: ___________ square feet
Number of floors in the residence: _________________
Number of bedrooms in the residence:
Number of bathrooms in the residence:

15. What type of heating does this residence have?
 Forced air  Radiator Other, specify:_________  Don’t know
Version 1.3 March 23, 2020

Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

Human Infection with 2019 Novel Coronavirus (nCoV)
Household Questionnaire V1.4 rev 3/23/2020
(Household Transmission Investigation)

State: ____WI________
Household ID: __WI-_________

16. Since the index patient developed symptoms on [insert date of symptom onset]:
a. Has air conditioning been used?
Yes
No
b. Has the household opened windows for ventilation?
Yes
No
c. Has any other form of ventilation (e.g. ceiling fans or portable fans) been used?
Yes
No
Index patient information
Note to interviewer: if the household member completing the interview is not the index patient, ask if the index
patient is available for several questions.
17. Are you still experiencing symptoms related to your COVID-19 illness?
Yes
No
Never had symptoms
If no, what date were you back to normal health? MM / DD / YYYY
18. Since you developed respiratory illness, have you done any of the following at home? (select all that apply)
 Slept alone in a bed
If yes, dates: ______________________________
 Slept alone in separate bedroom
If yes, dates: ______________________________
 Used a private bathroom (not shared)
If yes, dates: ______________________________
 Wore personal protective equipment
If yes, dates: ______________________________
Mask Gloves Other: ________________________________________________________
 Other: _________________________________
If yes, dates: ______________________________
19. Which household member has been assisting you as your primary caretaker during your illness?
Name: ______________________________________ None Unknown
20. What tasks has this primary caretaker assisted you with?
Taking temperature Serving meals Cleaning bedroom Cleaning bathroom Help with toileting
Other, specify _________________________________________________
Other:
21. Does the household have pets? Yes No
If yes, how many? _________ pets
Note to the interviewer: only include mammalian pets (no livestock).
Species (dog, cat)
Age (yrs) Indoor Pet? (y/n) Signs of illness? (y/n)
1.
2.
3.
4.

If ill, date of illness onset

Notes:

Version 1.3 March 23, 2020

Form Approved. OMB Control No. 0920-XXXX. Exp date. XX/XX/XXXX

Day of follow-up: 0/14 (Date of specimen collection)
Date (MM/DD/YYYY): ___________________________________
Name (First Last): ______________________________________
Household ID: WI-_________________
HH member ID: WI-_________________

Household Member Symptom Diary
1.

Who is providing this information today?
Self

Parent/guardian

Other, specify name: ___________________; relationship: _________________________
2.

What is the current time? ____________

Did you sleep in the household last night?

During the past 24 hours, have you experienced any of the following symptoms?

Yes

Symptom

Experienced in the past 24 hours?

Documented Fever >=100.4F (38C)
Highest temp ______F

Yes

Unknown

Subjective fever (felt feverish)
Chills
Fatigue (tired)
Headache
Muscle aches
Runny nose
Sore throat
Cough (new onset or worsening of chronic cough)
Dry
Productive
Discomfort/burning while breathing
Shortness of breath
Wheezing
Chest Pain
Nausea/Vomiting
Loss of taste
Complete
Partial
Loss of smell
Complete
Partial
Abdominal pain
Diarrhea (≥3 loose/looser than normal stools/24hr period)
Other, specify:

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No

Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown

Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No

Unknown
Unknown
Unknown
Unknown
Unknown
Unknown

Yes

Unknown

Yes
Yes
Yes

No
No
No

Unknown
Unknown
Unknown

Who should we contact for your daily reminder?

Other family member __________________________

Public reporting burden of this collection of information is estimated to average 10 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).

Preferred method of contact:

Phone call

Text

Form Approved. OMB Control No. 0920-XXXX. Exp date. XX/XX/XXXX

Phone/email:______________________________________________________________________

Public reporting burden of this collection of information is estimated to average 10 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).

Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX
Human Infection with SARS-CoV-2
Household Animal Questionnaire
This questionnaire is to be completed by primary caretaker for each pet/companion animal in the household.

State/local ID: _________
Household ID: _________
Pet/Animal ID: _________
Date interview completed: / /
(MM/DD/YYYY)
Interviewer Name:________________________________________ State/Local Health Department___________________________________
Who is providing information for this form?
□ Index COVID-19 patient
□ Other, specify name: ______________________________ Relationship to index patient: ____________________________________
How many pets/companion animals belong to the household? ________________________________ (Include service animals and any animals that
primarily live outside if the household members consider them “pets” and interact with them regularly.)

1. Pet Name: _________________________________________ Pet ID (e.g. 01, 02, 03…): _________________
a. Primary Caretaker of [PET NAME]: _________________________________________
b. Animal Type:  Dog  Cat  Other (please describe) ____________________________
a. Breed _________________________________________
c. Age of Pet (years/months): ____________________________________________________ years or months (Circle one)
d. Sex of Pet:  Male  Female
a. Has [PET NAME] been spayed/neutered:  Yes  No
2. Does [PET NAME] have any current health conditions?  Yes  No
a. If yes, please describe these health conditions or illnesses including when they started:
Condition
Date Started
Medications or supplement for the condition

b. Please describe any other medications or supplements that [PET NAME] takes.
3. On a regular day before [COVID-19 CASE] began home isolation, how long per day and what types of interaction
(e.g., walking, grooming, petting, cuddling) did [COVID-19 CASE] usually have with [PET NAME]?
a. Duration of interaction with pet per day:
<1 hour  1-3 hours  4-6 hours  7-9 hours  10-12 hours  12+ hours
b. Types of interaction/contact with pet (mark all that apply):
Taking for walks
Grooming
Feeding

Petting
Cuddling
Sleeping in the same location

Sharing food
Letting the pet lick their face or hands
Other (please describe): _________________

4. On a regular day since [COVID-19 case] started home isolation, how long per day and what types of interaction has
[COVID-19 CASE] had with [PET NAME]?
a. Duration of interaction with pet per day:
<1 hour  1-3 hours  4-6 hours  7-9 hours  10-12 hours  12+ hours
b. Types of interaction/contact with pet (mark all that apply):
 Taking for walks
 Petting
 Sharing food
 Grooming
 Cuddling
 Letting the pet lick their face or hands
 Feeding
 Sleeping in the same location  Other (please describe): _________________
c. Was [COVID-19 CASE] wearing any personal protective equipment (e.g. gloves or a cloth face covering)?
 Yes  No
a. If yes, please describe: ___________________________

“Public reporting burden of this collection of information is estimated to average 10 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).”

Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX
5. Is your pet:  Primarily indoors,  outdoors or  both?
a. If both, what percent of time is spent indoors? ____________%
b. Is [PET NAME] allowed anywhere in the house or restricted to certain areas? ________________
c. If restricted, specify where: ________________
6. On a regular day since [COVID-19 case] started home isolation, where does [PET NAME] go outside of the home
(mark all that apply)?
 On leash walks at park
 Dog park
 Free roaming in neighborhood/on property
 Doggy Daycare
 On leash walks in neighborhood/on property
 Service function (e.g. therapy dog)
 Indoors only
 Other (please describe): _________________________
7. Since [COVID-19 case] was diagnosed, has this pet developed any new health condition (mark all that apply)?
 Coughing
 Runny nose
 Sneezing
 Vomiting
 Difficulty breathing or shortness of breath
 Diarrhea
 Lethargy
 Other (please describe): __________________________
8. Have you/the patient heard or read about the CDC guidelines about a person who is sick restricting contact with
pets in the house?  Yes  No
9. Is there any additional information you think we should know about [PET NAME]?
a. If Yes: ___________________________________________________________________________
10. Are there small pets in the household, such as rats, mice, hamsters, gerbils, rabbits, or guinea pigs?  Yes  No
a. If Yes, please list the type of animal(s) and their name(s):
b. If No  Thank you for your time and participation.

Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

State: ____WI________
Household ID: __WI-_________

Human Infection with 2019 Novel Coronavirus (nCoV)
Household Close-Out Form V1.1 4/6/2020
(Household Transmission Investigation)

HOUSEHOLD CLOSE-OUT FORM
Please fill out this form when scheduling the final household visit.
1. Date of questionnaire: ____/____/________
2. Date of final household visit (i.e., last serum collection): ____/____/________
3. Is there extended symptom monitoring for confirmed cases beyond the final household visit?  Yes  No
If yes, please provide approximate end date of symptom monitoring for this household: ____/____/_____
4. Have you changed anything in your household behaviors to prevent spread in the family? Check all that are mentioned and DO NOT read the choices. Only include
behaviors/interventions since time of enrollment:
 Ill person/people (or persons diagnosed with COVID-19) wore a mask in the home
 My family is wearing masks, regardless of symptoms
 Ill person/people (or persons diagnosed with COVID-19) slept in a different room
 Ill person/people (or persons diagnosed with COVID-19) used a separate bathroom
 Ill person/people (or persons diagnosed with COVID-19) eat separately
 Ill person/people (or persons diagnosed with COVID-19) moved out of the house
 Used bleach wipes on high touch surfaces
 Used Lysol/cleaning spray on high touch surfaces
 Used Lysol/cleaning spray frequently in the bathroom
 Used Lysol/cleaning spray on high touch surfaces
 My family is washing hands frequently.
 My family stopped sharing plates/utensils/cups/food.
 My family increased the use of fans/open windows to increase air flow.
 My family stopped sharing common items like towels.
 My family is wearing gloves in the home.
 Other: specify_______________________________________________________________________________________________________________________
FINAL April 6, 2020

Public reporting burden of this collection of information is estimated to average 10 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).

Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

Human Infection with 2019 Novel Coronavirus (nCoV)
Household Close-Out Form V1.1 4/6/2020
(Household Transmission Investigation)

State: ____WI________
Household ID: __WI-_________

If a family member mentions wearing masks, ask questions 5-6:
5. What type of masks were worn (check all that apply):
 Cloth
 Medical/Surgical
 N-95
 Other, non-traditional mask (e.g., scarves, other barriers, etc.): specify_____________________________________________________________________
6. If there is more than 1 ill person (or persons diagnosed with COVID-19) in the household, did all ill people wear a mask?  Yes

 No

 Not applicable

7. Did any household pets become sick during the follow-up period?  Yes  No  Not applicable
If yes, describe symptoms and duration: ________________________________________
8. Please provide details for each household member in the table below:
Name
1.

Study ID

Hospitalized due
to COVID-19
 Yes
 No

Withdrawal?
Withdrawal?  Yes  No
If withdraw, date of withdrawal:
____/____/_______
Reasons: hospitalized, alive
deceased moved declined
other________________

 N/A

FINAL April 6, 2020

Public reporting burden of this collection of information is estimated to average 10 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).

Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

Human Infection with 2019 Novel Coronavirus (nCoV)
Household Close-Out Form V1.1 4/6/2020
(Household Transmission Investigation)

State: ____WI________
Household ID: __WI-_________
Name
2.

Study ID

Hospitalized due
to COVID-19
 Yes
 No

 Yes
 No

If confirmed by PCR, provide
preliminary determination of
primary vs. secondary cases*
 Primary case
 Secondary case
if secondary, suspected outside
infection? Yes No, explain:
______________________________
______________________________
______________________________
 N/A
 Primary case
 Secondary case
if secondary, suspected outside
infection? Yes No, explain:
______________________________
______________________________
______________________________
 N/A
 Primary case
 Secondary case
if secondary, suspected outside
infection? Yes No, explain:
______________________________
______________________________
______________________________

Withdrawal?
Withdrawal?  Yes  No
If withdraw, date of withdrawal:
____/____/_______
Reasons: hospitalized, alive
deceased moved declined
other________________
Withdrawal?  Yes  No
If withdraw, date of withdrawal:
____/____/_______
Reasons: hospitalized, alive
deceased moved declined
other________________
Withdrawal?  Yes  No
If withdraw, date of withdrawal:
____/____/_______
Reasons: hospitalized, alive
deceased moved declined
other________________

 N/A

FINAL April 6, 2020

Public reporting burden of this collection of information is estimated to average 10 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).

Form Approved: OMB: 0920-XXXX Exp. XX/XX/XXXX

Human Infection with 2019 Novel Coronavirus (nCoV)
Household Close-Out Form V1.1 4/6/2020
(Household Transmission Investigation)

State: ____WI________
Household ID: __WI-_________
Name
5.

Study ID

Hospitalized due
to COVID-19
 Yes
 No

Withdrawal?
Withdrawal?  Yes  No
If withdraw, date of withdrawal:
____/____/_______
Reasons: hospitalized, alive
deceased moved declined
other________________

 N/A
*The determination can be made at the time the patient is confirmed to be positive (i.e., at baseline, an interim visit, or day 14)

Notes for field investigators:
- Primary case/s
o Primary case is the confirmed COVID-19 case with the earliest symptom onset in the household. Oftentimes, this will be the index patient.
o If there are multiple household cases who have the earliest symptom onset (within a day; or, not within a day but they have a known common exposure),
we will consider them as co-primary cases who introduced the virus into the household. Please check them as primary cases in the table.
- Secondary cases
o Ideally, we’d like to identify secondary cases as household members who are subsequently infected by the primary case/s.
o However, in practice, we may not be able to differentiate secondary vs. tertiary (or further generations of) transmission, or infections due to exposure
outside of the household
o Thus, for now, we plan to consider all subsequent infections in the household as secondary cases, and estimate the overall risk of infection (i.e., %
household members subsequently infected) as a proxy for household secondary attack rate
 This approach assumes that all subsequent infections in the household are due to exposures to the primary case/s
 As the above assumption may be violated, please mark household cases with suspected/known infection due to outside sources as; as a sensitivity analysis,
we will consider excluding them when estimating the secondary attack rate
FINAL April 6, 2020
4
Public reporting burden of this collection of information is estimated to average 10 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 Type	application/pdf
Author	acy9
File Modified	2020-07-08
File Created	2020-07-08