Fillable Form 1: Interim Coronavirus Disease 2019 (COVID-19) Case (Texas Secretary of State)

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Form 1: Interim Coronavirus Disease 2019 (COVID-19) Case (Texas Secretary of State)

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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
_________
Patient’s Name:
Address:
City:
County:
State:
Date of Birth:
Home Phone:
Cell Phone:
Email:
STATE ID:
Date of Report:
County:
State:
Investigator’s name:
Phone:
Investigation Start Date:
Physician’s name:
Phone/Pager:
Reporter’s Name:
Phone:
Email:
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.
☐ Y ☐ N ☐ Unknown
Have close contact
3
with a person who is under investigation for COVID-19?
☐ Y ☐ N ☐ Unknown
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.
☐ Y ☐ N ☐ 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
Clear Form
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 3/17/2020 Page 2 of 3
Provide care for a COVID-19 patient? ☐ 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 COVID-19 is being evaluated? ☐ Y ☐ N ☐ Unknown
Diagnosis (select all that apply): Pneumonia (clinical or radiologic) ☐ Y ☐ N Acute respiratory distress syndrome ☐ Y ☐ N
Co-morbid conditions (check all that apply): ☐ None ☐ Unknown ☐ Pregnant ☐ 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 Date Admitted to ICU:
Intubated? ☐ Y ☐ N ☐ Unk On ECMO? ☐ Y ☐ N ☐ Unk Patient died? ☐ Y ☐ N If yes, date of death: __/__/____
Discharged from hospital? ☐ Y, DC date_____________ ☐ N Is the patient isolated at home? ☐ Y ☐ N
Does the patient have another diagnosis/etiology for their respiratory illness? ☐ Y, Specify______________ ☐ N ☐ Unknown
Additional Comments (smoking status, other comorbidities, potential contacts/places of exposure, etc.):
Where did COVID-19 testing
4
occur? ☐ Commercial or Hospital Lab Please specify: __________________
☐ Texas DSHS Laboratory Response Network (LRN) Lab Please specify: ______________
☐ DSHS-Austin Lab
RESPIRATORY DIAGNOSTIC RESULTS
Test
Pos
Neg
Pending
Not done
Influenza rapid Ag ☐ A ☐ B
☐
☐
☐
☐
Influenza PCR ☐ A ☐ B
☐
☐
☐
☐
RSV
☐
☐
☐
☐
H. metapneumovirus
☐
☐
☐
☐
Parainfluenza (1-4)
☐
☐
☐
☐
Adenovirus
☐
☐
☐
☐
Test
Pos
Neg
Pending
Not done
Rhinovirus/enterovirus
☐
☐
☐
☐
Coronavirus (OC43, 229E,
HKU1, NL63)
☐
☐
☐
☐
M. pneumoniae
☐
☐
☐
☐
C. pneumoniae
☐
☐
☐
☐
Other, Specify_________
☐
☐
☐
☐
SPECIMENS FOR COVID-19 TESTING
1
For NNDSS reporters, use GenV2 or NETSS patient identifier.
2
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
3
Close contact is defined as—
Specimen type
Specimen ID
Date collected
Date Resulted
Lab Name
Commercial
Public Health
NP swab
☐
☐
OP swab
☐
☐
Sputum
☐
☐
BAL fluid
☐
☐
Tracheal aspirate
☐
☐
Stool
☐
☐
Postmortem
Specify:
☐
☐
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 3/17/2020 Page 3 of 3
a) being within approximately 6 feet (2 meters) of a COVID-19 case for a prolonged period of time; close contact can occur while caring for, living with, visiting, or sharing a
health care waiting area or room with a COVID-19 case
– or –
b) having direct contact with infectious secretions of a COVID-19 case (e.g., being coughed on)
If such contact occurs while not wearing recommended personal protective equipment or PPE (e.g., gowns, gloves, NIOSH-certified disposable N95 respirator, eye
protection), criteria for PUI consideration are met”
See CDC’s updated guidance for infection control on their website for specific relevant guidance: https://cdc.gov/coronavirus
Data to inform the definition of close contact are limited. Considerations when assessing close contact include the duration of exposure (e.g., longer exposure time likely
increases exposure risk) and the clinical symptoms of the person with 2019-nCoV (e.g., coughing likely increases exposure risk as does exposure to a severely ill patient).
Special consideration should be given to those exposed in health care settings.
4
All presumptive positive test results for COVID-19 disease are considered to be cases.
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Form 1: Interim Coronavirus Disease 2019 (COVID-19) Case (Texas Secretary of State)

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Completed 23 May 2021

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