Interim Coronavirus Disease 2019 (COVID-19) Case Report Form
Local health departments should submit this report to the regional health department.
Regional health departments should fax this report to 512-776-7616.
Version 1.0 – Released 3/20/2020 Page 1 of 3
Today’s date__________ NNDSS local record ID/Case ID
1
_________
Investigation Start Date:
PATIENT DEMOGRAPHIC INFORMATION
Sex: ☐ M ☐ F Age: _______ ☐ yr ☐ mo Residency: ☐ U.S. resident ☐ Non-U.S. resident, country: ________________________________
Race: ☐ White ☐ Black ☐ Asian ☐ Pacific Islander ☐ Native American/Alaskan ☐ Unknown ☐ Other: _____________________________
Hispanic: ☐ Yes ☐ No ☐ Unknown
Occupation: ____________________________________ ☐ Unemployed ☐Student, Name of School: ________________________
CASE CRITERIA
Date of symptom onset _____________________ ☐ Asymptomatic
Does the patient have the following signs and symptoms (check all that apply)?
☐ Fever
2
☐ Cough ☐ Sore throat ☐ Shortness of breath
Does the patient have these additional signs and symptoms (check all that apply)?
☐ Chills ☐ Headache ☐ Muscle aches ☐ Vomiting ☐ Abdominal pain ☐ Diarrhea ☐ Other, Specify _______________
In the 14 days before symptom onset, did the patient:
Travel outside their city of residence?
If yes, list destinations and dates*: Date arrived (MM/DD/YY) Date left (MM/DD/YY)
1. __________________________ ____/____/_____ _____/____/______
2. __________________________ ____/____/_____ _____/____/______
3. __________________________ ____/____/_____ _____/____/______
*Please list any additional travel destinations or information in the comments section.
Have close contact
3
with a person who is under investigation for COVID-19?
Have close contact
3
with a laboratory-confirmed COVID-19 case?
Was the case ill at the time of contact?
Is the case a U.S. case?
Is the case an international case?
In which country was the case diagnosed with COVID-19?
______________________________
☐ Y ☐ N ☐ Unknown
☐ Y ☐ N ☐ Unknown
☐ Y ☐ N ☐ Unknown
☐ Y ☐ N ☐ Unknown
No known exposure history (suspected community transmission)
Only check Y if you have been able to confirm that the patient has no exposure risk factors such
as travel, contact with a confirmed or suspected case, providing care for a confirmed case, etc. If
you are unable to ascertain exposure history, check Unknown.
ADDITIONAL PATIENT INFORMATION
Is the patient a healthcare worker? ☐ Y ☐ N ☐ Unknown
Have history of being in a healthcare facility (as a patient, worker, or visitor)? ☐ Y ☐ N ☐ Unknown