Fillable CRF-COVID-19 MERS Coronavirus (Middle East Respiratory Syndrome) Case Report Form

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CRF-COVID-19 MERS Coronavirus (Middle East Respiratory Syndrome) Case Report Form

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Country of origin: AUSTRALIA
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Case name: .........................................................................................
DOB: ......../......../........ Notification ID: ..............................
First name
Surname
Surveillance of Notifiable Conditions – COVID-19
27 March 2020
1 of 2
Queensland Health
...............................................................................
COVID-19 Case Report Form
Public Health Unit Outbreak ID: ......................................
Completed by: .......................................................................................... Date sent to NOCS: ......../......../.........
Telephone: ............................................... Fax: .................................................
CASE DETAILS: UR No: ....................................................................................
Name:
....................................................................................................................................................................................................................
First name
Surname
Date of birth: ......../......../........ Age: ..........Years ......... Months Sex: M ale F emale
Aboriginal Torres Strait Islander Aboriginal & Torres Strait Islander Non-Indigenous Unknown
Permanent address:
...................................................................................................................................................................................................
.................................................................................................................................................................
Postcode: ...............................................
Home telephone: .......................................... Mobile: ..................................
Email:
......................................................................................
Accommodation type: p rivate residence hospital psych facility prison/remand a ged care hostel/boarding
mining camp
other (High risk settings as per current SoNG) -
specify
..................................................................................................
Temporary address in Queensland
(if different from permanent address)
: ......................................................................................................
...................................................................................................................................................................
Postcode: ..............................................
Telephone: ........................................ Mobile: ..................................
Email:
.....................................................................................
CLINICAL DETAILS:
Onset first symptoms:
......../......../........ Time: ...............am/pm
Fever >38
o
C …………ºC Fever by self-report Cough Sore throat
Runny nose Shortness of breath Diarrhoea Nausea/vomiting
Headache Irritability/confusion Muscular pain Chest pain
Abdominal pain Joint pain Acute respiratory disease /syndrome
Pneumonia;
Specify
- Clinical evidence Radiological evidence
Other-
Specify
:
........................................................................................
Unknown
MEDICAL MANAGEMENT:
Hospitalised:
Yes No Unknown If Yes-
specify
Hospital: ........................... Date: ......../......../........ to ......../......../........
ICU admission:
Yes No Unknown If Yes
specify
Ventilated: Yes No NAUnknown
Isolation:
Yes No Unknown If Yes-
specify
Location: ........................... Date: ......../......../........ to ......../......../........
Negative Pressure Room:
Yes No Unknown
Did the case receive Extracorporeal Membrane Oxygenation (ECMO)? Yes No Unknown
Antiviral drugs –
specify
.........................................................................................................................................................................
CASE FOUND BY:
Clinical presentation Contact tracing / Epidemiological investigation Screening (Excluding antenatal)
Clinical and Epidemiology Antenatal screening Unknown
COMORBIDITIES:
None Asthma Chronic respiratory condition (excluding asthma)
Cardiac disease (excluding hypertension) Immunosuppressive condition/therapy
Diabetes Obesity Liver disease
Renal disease Neurological disorder Pregnant -Specify: Gestation week: ...............
Other ...................................................................................................... Unknown
Case name: .........................................................................................
DOB: ......../......../........ Notification ID: ..............................
First name
Surname
Surveillance of Notifiable Conditions – COVID-19
27 March 2020
2 of 2
Queensland Health
TRAVEL HISTORY:
Did the person travel outside of the country/state/region in the 14 days before onset?
Yes No Unknown
Country / state:
....................................................................................................................................................................
Region/city:
..........................................................................................................................................................................
Flight details: (return to Brisbane): Flight Number: ............................................... Row/seat/cabin: ...............................................
Arrival date: ......../......../........ (dd/mm/yyyy) Departure date: ......../......../........ (dd/mm/yyyy)
Able to enter travel-specific details (i.e. mode of transport, flight numbers, etc.)? Yes No
If Yes, mode(s) of transportation (check all that apply):
Airplane Ship/boat/ferry Bus Train Other
Did the person move (seat) during flight journey?
Yes No Unknown
In transit/ stop over?
Yes No Unknown
If yes, specify details:
.....................................................................................................................................................................
Was travel with an organized tour? Yes No Unknown
OTHER TRAVEL INFORMATION:
1. Arrival date: ......../......../........ Departure date: ......../......../........ Flight / Trip Number: ......................
Row/seat/cabin: ...................... Departure from: ......................
Arrived in: ......................
2. Arrival date: ......../......../........ Departure date: ......../......../........ Flight / Trip Number: ......................
Row/seat/cabin: ......................Departure from: ...................... Arrived in: ......................
3. Arrival date: ......../......../........ Departure date: ......../......../........ Flight / Trip Number: ......................
Row/seat/cabin: ...................... Departure from: ......................
Arrived in: ......................
PLACE ACQUIRED:
Queensland Other Australian state/territory –
specify
...........................................................................................................
Unknown Other country
– specify
...........................................................................................................................................
SOURCE OF INFECTION:
Overseas acquired Locally acquired (epi-link to local case)
Locally acquired (epi-link to imported case)
Locally acquired (unknown epi-link) Under Investigation Not Applicable
CLOSE CONTACTS DETAILS:
Healthcare associated exposure Contact with a known case – workplace
Contact with a known case – household
Contact with a known case – travel Other ..................................................................... Unknown
NOTIFICATION DECISION:
Confirmed COVID-19 case Probable COVID-19 case
Suspect COVID-19 case
OUTCOME: Recovered / Cleared the virus as per current SoNG
Died Date of death: ......../......../........ Died of condition Unknown
If patient died, was an autopsy conducted?
Yes No Unknown
Autopsy results:
........................................................................................
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CRF-COVID-19 MERS Coronavirus (Middle East Respiratory Syndrome) Case Report Form

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Completed 29 March 2020

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