Fillable SF Department of Public Health COVID-19 Case Report

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SF Department of Public Health COVID-19 Case Report

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Date of Symptom Onset (if known) Name of testing site Location of testing site
Type of test Date of test Test results Pregnant
Yes No Unknown
Hospitalization
Outpatient ED Admitted (ll-in details below) Not admitted
Patient in ICU?
Yes No Unknown
Additional comments
Patient intubated? *If yes, date of death
Yes No Unknown
Did patient die?
Yes* No
Next of kin name Relationship to deceased Phone
Next of kin home address City, State, Zip Email
COVID-19 Case: Clinical Status and Laboratory Information
*If yes, immediately call the Public
Health Department: 415-554-2830
Asymptomatic
MIS-C (multi-inammatory
syndrome in children)
Today’s date Healthcare provider email
Healthcare provider name Healthcare provider phone
Clinic, hospital, or other location of healthcare provider
SF Department of Public Health COVID-19
Case Report Form
CMR 063020
Patient last name Patient rst name
Date of Birth MRN Preferred language
Gender Other specify* Sexual orientation
Ethnicity (check all that apply)
African American/ Black Asian Native Hawaiian or Other Pacific Islander (NHOPI) Native American/Alaskan
Latino/a White Multi-ethnic Unknown
Housing type
Home Address City, State, Zip
Phone Email
Occupation
N/A
Occupation/School Location (Name & address)
COVID-19 Case: Information
*Facility name
1
Select
Select
Select
Please list household contacts, intimate partners, or any other close contacts:
First name Last name DOB ~Age Phone
Preferred language Type of contact Specify setting (name/location/phone) Date of last contact
Known test status
Positive Negative Unknown None Scheduled
Date of test Risk factors
Pregnant Immune suppression
First name Last name DOB ~Age Phone
Preferred language Type of contact Specify setting (name/location/phone) Date of last contact
Known test status
Positive Negative Unknown None Scheduled
Date of test Risk factors
Pregnant Immune suppression
First name Last name DOB ~Age Phone
Preferred language Type of contact Specify setting (name/location/phone) Date of last contact
Known test status
Positive Negative Unknown None Scheduled
Date of test Risk factors
Pregnant Immune suppression
First name Last name DOB ~Age Phone
Preferred language Type of contact Specify setting (name/location/phone) Date of last contact
Known test status
Positive Negative Unknown None Scheduled
Date of test Risk factors
Pregnant Immune suppression
Close Contacts
COVID-19 Case: continued
Did patient have close contact with lab conrmed COVID-19?
Yes No Unknown
Can case safely self-isolate in their own room and bathroom?
Yes No (please refer to I/Q hotel) Unknown
2
Resources
• Those unable to isolate or quarantine may be referred for temp alt housing via the web-based form at
https://covid19isorequest.getcare.com/referral
• If patients or contacts have social needs, refer to COVID food resources via clinic social worker, email
iqfeedingunit@sfgov.org or direct patient to call 311
• CityTestSF website: sf.gov/nd-out-how-to-get-tested-coronavirus
• SF Health Network New Patient Line: 415-682-1740
• Link to SFDPH self-isolation/self-quarantine documents
• Mail/send via mychart DPH self-isolation documents. See sfcdcp.org/covid-19, under “Isolation and Quarantine
Directives”
Other
Other
Other
Other
3
First name Last name DOB ~Age Phone
Preferred language Type of contact Specify setting (name/location/phone) Date of last contact
Known test status
Positive Negative Unknown None Scheduled
Date of test Risk factors
Pregnant Immune suppression
First name Last name DOB ~Age Phone
Preferred language Type of contact Specify setting (name/location/phone) Date of last contact
Known test status
Positive Negative Unknown None Scheduled
Date of test Risk factors
Pregnant Immune suppression
First name Last name DOB ~Age Phone
Preferred language Type of contact Specify setting (name/location/phone) Date of last contact
Known test status
Positive Negative Unknown None Scheduled
Date of test Risk factors
Pregnant Immune suppression
First name Last name DOB ~Age Phone
Preferred language Type of contact Specify setting (name/location/phone) Date of last contact
Known test status
Positive Negative Unknown None Scheduled
Date of test Risk factors
Pregnant Immune suppression
First name Last name DOB ~Age Phone
Preferred language Type of contact Specify setting (name/location/phone) Date of last contact
Known test status
Positive Negative Unknown None Scheduled
Date of test Risk factors
Pregnant Immune suppression
First name Last name DOB ~Age Phone
Preferred language Type of contact Specify setting (name/location/phone) Date of last contact
Known test status
Positive Negative Unknown None Scheduled
Date of test Risk factors
Pregnant Immune suppression
First name Last name DOB ~Age Phone
Preferred language Type of contact Specify setting (name/location/phone) Date of last contact
Known test status
Positive Negative Unknown None Scheduled
Date of test Risk factors
Pregnant Immune suppression
Other
Other
Other
Other
Other
Other
Other
Clear Form
4
For the following categories of suspected OR lab-conrmed COVID-19 cases, please immediately call the
SFDPH COVID-19 Clinical Consultation Line at (415) 554-2830 to report:
• Fatal conrmed case
• Case who is a patient or sta in a long-term care or skilled nursing facility
• Case who is experiencing homelessness, and/or living in congregate settings such as shelters, navigation centers,
SROs, group residential, or correctional facilities
• Case who is a patient with MIS-C (Multi-Inammatory Syndrome in Children)
• A cluster of 3 or more cases in health care workers at the same facility
• A cluster of 3 or more cases of unexplained pneumonia or deaths in a congregate setting not listed above
For lab-conrmed COVID-19 cases, please submit case reports within 24 hours of diagnosis by email or fax to
SFDPH:
• Download a COVID-19 CMR fromwww.sfcdcp.org/covid19cmr
• Complete all relevant fields
• Send the complete form and supporting laboratory results via secure/encrypted email to cdcontrol@sfdph.org and
and
trace@sfdph.org or fax both documents to (628) 217-7599
For the following situations, please contact the Clinical Consultation Line (415) 554-2830 for assistance with
contact tracing: visited a healthcare facility, went to work, went to school, attended an event or meeting, attended a
party, attended a funeral, went to religious service, visited a LTCF of SNF type of facility, or went on any ights
For additional questions about this form, please call (415) 554-2830 and follow the prompts to reach the
Clinical Consultation Line.
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SF Department of Public Health COVID-19 Case Report

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Completed 8 January 2021

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