Fillable Novel Coronavirus 2019 (COVID-19)-NSW-Case-Questionnaire

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Novel Coronavirus 2019 (COVID-19)-NSW-Case-Questionnaire

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Novel Coronavirus 2019 (COVID-19) NSW Case Questionnaire
Last updated: 23 March 2020
NOTIFICATION DATE: : / / (dd/mm/yyyy) DATE OF INTERVIEW: / / (dd/mm/yyyy)
NCIMS ID: ......................... Interviewer name: __________________________
1
Patient
contact details
Family name: Given names:
Street address:
Suburb/ Town: State: Postcode:
Country:
Home phone: Mobile phone:
Work phone: Email:
2
Address type
Household Aged-care facility Educational Institution Assisted Living
Military Barracks Prison Other Unknown
If Other, please specify:
3.
Was an
interpreter
used?
Yes No If Yes, name of interpreter and language spoken
4.
Reason for
interview
(tick as many
as apply)
Contact with known case Overseas travel
Occupational exposure Reported recent risk exposure / contact
Symptomatic of disease Other
If Other, specify
5
Gender
Male Female Unknown
6
Date of birth
Birth date: / / (dd/mm/yyyy)
7
Country of
birth
8
Indigenous
Status
Aboriginal origin
Torres Strait Islander origin
Both Aboriginal and Torres Strait Islander origin
Not Aboriginal and Torres Strait Islander origin
Not Stated / Unknown
RISK HISTORY - in the past 14 days
9
Travel in the
risk period
Did the person travel outside of the country/state/region in the 14 days before onset?
Yes No UK
Country:
City / region:
dd mmm yyyy
dd mmm yyyy
dd mmm yyyy
Novel Coronavirus 2019 (COVID-19): Case Questionnaire (2.0)
2
FLIGHT DETAILS: (return to Sydney)
Flight Number: Seat:
Arrival date: / / (dd/mm/yyyy) Departure date: / / (dd/mm/yyyy)
Was travel with an organised tour? Yes No UK
Type of accommodation: Private Hotel Camping Hostel Other Unknown
- If Other, specify:
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
In transit / stop over? Yes No UK
10
Other Travel
information
1. Date: / / (dd/mm/yyyy) Carrier: Flight # / trip #:
Seat / cabin: Departed from: Arrived in:
2. Date: / / (dd/mm/yyyy) Carrier: Flight # / trip #:
Seat / cabin: Departed from: Arrived in:
3. Date: / / (dd/mm/yyyy) Carrier: Flight # / trip #:
Seat / cabin: Departed from: Arrived in:
Travel Notes:
11
Contact with a
known or
possible case
(during period
of interest)
Did the case have contact with a known or possible COVID-19 case? Yes No UK
If Yes, specify:
Date of last contact: / / (dd/mm/yyyy)
12
Likely source
of infection
Acquired overseas
Acquired Interstate
Locally acquired - Health care associated exposure
Locally acquired - Contact with a known case - other
Locally acquired - Contact with a known case - household
Locally acquired - Part of a known cluster – details: _________________________________
Locally acquired - Source not identified
Under investigation
CLINICAL PRESENTATION
13
Onset date of
first
symptoms
Did the person have symptoms? Yes No UK
- If Yes, onset date: / / (dd/mm/yyyy)
- Duration of symptoms: (days) [if symptoms have resolved]
Novel Coronavirus 2019 (COVID-19): Case Questionnaire (2.0)
3
14
Symptoms
Acute respiratory distress syndrome
Yes No UK
Confirmed by X ray? Yes No UK
Arthralgia Yes No UK
Cough Yes No UK
Conjunctivitis Yes No UK
Diarrhoea Yes No UK
Diarrhoea onset date: / /
Fatigue Yes No UK
Fever Yes No UK
Highest temperature: (Celsius)
Where recorded
Highest date: / /
Feverish self-report? Yes No
UK
Chills or rigors Yes No UK
Headache Yes No UK
Malaise Yes No UK
Myalgia Yes No UK
Nausea Yes No UK
Pneumonia Yes No UK
Confirmed by X ray? Yes No UK
Pneumonitis Yes No UK
Rhinorrhoea Yes No UK
Shortness of breath Yes No UK
Sore throat Yes No UK
Vomiting Yes No UK
Other symptoms? Yes No UK
- If Yes, specify symptoms:
Clinical notes:
15
Clinical
outcome
Was the person hospitalised? Yes No UK
- Name of hospital:
- Hospital phone number:
Novel Coronavirus 2019 (COVID-19): Case Questionnaire (2.0)
4
- Date admitted: / / Date discharged: / / (dd/mm/yyyy)
Admitted to ICU/HDU? Yes No UK
- Number of days in ICU/HDU: (days)
Oxygen therapy required? Yes No UK
Intubation required? Yes No UK
Mechanical ventilation required? Yes No UK
Hospital medical record/chart number:
16
Has the
person died?
What was the outcome of the case? Alive Died
- If Died, date of death: / / (dd/mm/yyyy)
- Cause of death due to COVID-19 infection? Yes No UK
- If death due to other cause, specify:
17
Admitting
doctor details
Is the Admitting Doctor same as treating doctor? Yes No UK
If Yes, enter details in the Treating Doctor section below if required.
If No, Admitting Doctor’s name:
- Phone number / pager
18
Treating
Doctor’s
details
Treating Doctor’s name:
Practice name (if any):
Address:
State: Postcode:
Phone / pager number: Fax number:
Email address:
19
Outcome of
illness
What was the outcome of the case? Alive Died
- If Died, date of death: / / (dd/mm/yyyy)
- Cause of death due to COVID-19 infection? Yes No UK
- If death due to other cause, specify:
20
Pre-existing
conditions
and medical
history
No risk medical condition Yes No UK
Cardiac disease (not simple hypertension) Yes No UK
Chronic lung disease Yes No UK
Diabetes Yes No UK
- If Yes, are they on dialysis? Yes No UK [manual entry]
dd mmm yyyy
dd mmm yyyy
Novel Coronavirus 2019 (COVID-19): Case Questionnaire (2.0)
5
Haemoglobinopathies Yes No UK
Immunosuppressive condition Yes No UK
Liver disease Yes No UK
Metabolic disease Yes No UK
Neurological disorder Yes No UK
Obesity Yes No UK
Renal disease Yes No UK
Other risk medical condition? Yes No UK
- If Yes, specify:
Pre-existing medications and conditions notes:
21
Other Risk
Factors
Is the person currently pregnant or pregnant during the illness? Yes No UK
- If Yes, number of weeks gestation at symptom onset: (weeks)
Are they a current smoker? Yes No UK
- If Yes, number of pack years: (pack/yrs)
Do they drink alcohol? Yes No UK
- If Yes, average number of standard drinks per week: (SD/week)
EXPOSURE SITES
22
Healthcare
and hospital
presentations
Did the case present to a hospital in the 14 days prior to onset with COVID-19 symptoms?
Yes No UK
If Yes, date of presentation to hospital: / / (dd/mm/yyyy)
If Yes, give details of the presentation and illness:
Did the case present to a hospital during the 14 days prior to onset with other symptoms?
Yes No UK
If Yes, date of presentation to hospital: / / (dd/mm/yyyy)
If Yes, give details of the presentation and illness:
Did the case present to any other health care facility in the 14 days prior to onset with COVID-
19 symptoms (e.g. a GP practice)? Yes No UK
If Yes, date of presentation to hospital: / / (dd/mm/yyyy)
If Yes, give details of the presentation and illness:
Novel Coronavirus 2019 (COVID-19): Case Questionnaire (2.0)
6
POSSIBLE CONTACTS – In the period from 24 hours prior to onset of symptoms to today
23
During the period of interest, did the person work in any of the following high-risk occupations?
Healthcare Aged-care facility Educational facility
Assisted Living Military institution Correctional facility
No high-risk occupation Other Unknown
If Other, specify:
Date last attended this work: / / (dd/mm/yyyy)
Was the infection likely acquired in the workplace? Yes No UK
Description of occupation:
Employer/Facility details:
Address:
State: Postcode:
Phone number: Fax number:
Employer Contact name:
Contact email address:
24
While infectious, did they visit any of the following venues or locations?
Doctor’s rooms/ clinic / emergency department Y N UK
Schools / universities / TAFE Y N UK
Aged care facilities / assisted living Y N UK
Transport (plane / train / bus / ship) Y N UK
Concert venue / theatre / conference Y N UK
Office / workplace Y N UK
Other public venue / gathering Y N UK
If yes, give details:
Novel Coronavirus 2019 (COVID-19): Case Questionnaire (2.0)
7
25
While infectious, did they have close contact with any of the following:
family members housemates friends
If yes, give details (including name, phone number, email address):
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Completed 29 March 2020

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