Santa Clara County COVID-19 Confirmed Case Report FormRev 10.13.20
Santa Clara County COVID-19 Case Report Form (For instructions see Reporting COVID-19 Cases”)
Send via secure email (coronavirus@phd.sccgov.org) or secure fax (408-224-7046)
Today’s date: ___________ Healthcare Provider Name: ______________________ Provider phone:__________________
Clinic/Hospital Name:_____________________________________________________________________________
COVID-19 confirmed case home and work information
Patient last name: ________________________________ Patient first name: ______________________________________
Date of birth: __________________ Primary language: ________________ MRN:________________________________
Race:
American Indian/Alaskan Native
Asian
Black/African American
White
Native Hawaiian or other Pacific Islander
Other
Reported Race: ___________________
Unknown
Ethnicity: Hispanic Non-Hispanic Unknown
Current Gender identity: Male Female Trans male/Transman Trans female/Transwoman
Genderqueer or non-binary Identity not listed Declined to answer Unknown
Sex assigned at birth:
Male Female Declined to answer Unknown
Sexual orientation: Heterosexual or straight Bisexual Gay, lesbian, or same gender loving Orientation not listed
Questioning/unsure/patient doesn’t know Declined to answer Unknown
Housing: Stable housing Shelter Homeless Jail Long-term care facility Dormitory
Work/Live in congregate setting? Yes* No *If yes, is person: Resident Staff
For Congregate Setting (name & type): _____________________________________________________________________
Home address: _______________________________ City: ______________________ State: ______________ Zip: _________
Cell phone #: _______________________ Occupation:____________________________________________________
Workplace/School and location (Name and/or address, please list all): _____________________________________________
________________________________________________________________________________________________________
Clinical Status
Date of positive COVID19 test: __________ MIS-C (Multisystem Inflammatory Syndrome in Children) Yes No
Was case ever symptomatic? Yes
Specify symptoms:
Cough
Fever or chills
Fatigue
Sore throat
No
Yes* *
If yes, date of death: _______________
Pregnant: No Yes
Hospitalization:
No
Yes*
Unknown *If yes, fill in details below about hospitalization Hospital Admit Date: __________
Patient in ICU? No Yes Unknown Additional Comments:
Patient on ECMO? No Yes Unknown
Patient intubated? No Yes Unknown
Comorbidities?
None
Unknown
COPD
Other Chronic Lung Disease: ___________________________
Asthma
Chronic Renal Disease
Cardiovascular
Immunocompromised, specify: __________________________
Diabetes
Chronic Liver Disease
Current smoker
⃝⃝ Other comorbidities: __________________________________
Other Health Risks:
Former smoker
Neurologic/neurodevelopmental conditions: ________________
No Date of symptom onset (if known): _______________________________
Did the patient die?
M
uscle/body aches
Headache Loss of taste or smell
Nausea, diarrhea and/or vomiting
Other
SOB/Difficulty breathing
Contacts
Did patient have close contact with a lab confirmed COVID-19 case?
No
Yes
Unknown
If yes, type of contact:
Household contact
Community contact
Any healthcare contact*
If healthcare contact, specify:
Patient
Visitor
Healthcare worker
If healthcare contact, specify healthcare facility location: ___________________________________________________________
I did not elicit close contacts. Below is the contact information for the patient’s next of kin.
The close contacts I was able to elicit are listed below.
I have already contacted them.
I did not contact them.
Next of Kin: Name
_________________________________________ Phone_______________________________
Close Contact #1:
Last Name: _______________________ First Name: ____________________ Date of Last Exposure: ______________
DOB:___________ Age: _____ Phone Number: _________________________ Language: ____________________________
Household Contact: Yes No Notified: Yes No
Comments (i.e. relationship, any information caller will need): ________________________________________________________
__________________________________________________________________________________________________________
Close Contact #2:
Last Name: _______________________ First Name: ____________________ Date of Last Exposure: ______________
DOB:___________ Age: _____ Phone Number: _________________________ Language: ____________________________
Household Contact: Yes No Notified: Yes No
Comments (i.e. relationship, any information caller will need): ________________________________________________________
__________________________________________________________________________________________________________
Close Contact #3:
Last Name: _______________________ First Name: ____________________ Date of Last Exposure: ______________
DOB:__________ Age: _____ Phone Number: _________________________ Language: ____________________________
Household Contact: Yes No Notified: Yes No
Comments (i.e. relationship, any information caller will need): ________________________________________________________
__________________________________________________________________________________________________________
Close Contact #4:
Last Name: _______________________ First Name: ____________________ Date of Last Exposure: ______________
DOB:___________ Age: _____ Phone Number: _________________________ Language: ____________________________
Household Contact: Yes No Notified: Yes No
Comments (i.e. relationship, any information caller will need): ________________________________________________________
__________________________________________________________________________________________________________
Close Contact #5:
Last Name: _______________________ First Name: ____________________ Date of Last Exposure: ______________
DOB:__________ Age: _____ Phone Number: _________________________ Language: ____________________________
Household Contact: Yes No Notified: Yes No
Comments (i.e. relationship, any information caller will need): ________________________________________________________
__________________________________________________________________________________________________________
Continue listing additional contacts on the next pages, if needed.
Santa Clara County COVID-19 Confirmed Case Report FormRev 10.13.20
Santa Clara County COVID-19 Confirmed Case Report FormRev 10.13.20
Close Contact #6:
Last Name: _______________________ First Name: ____________________ Date of Last Exposure: ______________
DOB:___________ Age: _____ Phone Number: _________________________ Language: ____________________________
Household Contact: Yes No Notified: Yes No
Comments (i.e. relationship, any information caller will need): ________________________________________________________
__________________________________________________________________________________________________________
Close Contact #7:
Last Name: _______________________ First Name: ____________________ Date of Last Exposure: ______________
DOB:___________ Age: _____ Phone Number: _________________________ Language: ____________________________
Household Contact: Yes No Notified: Yes No
Comments (i.e. relationship, any information caller will need): ________________________________________________________
__________________________________________________________________________________________________________
Close Contact #8:
Last Name: _______________________ First Name: ____________________ Date of Last Exposure: ______________
DOB:__________ Age: _____ Phone Number: _________________________ Language: ____________________________
Household Contact: Yes No Notified: Yes No
Comments (i.e. relationship, any information caller will need): ________________________________________________________
__________________________________________________________________________________________________________
Close Contact #9:
Last Name: _______________________ First Name: ____________________ Date of Last Exposure: ______________
DOB:___________ Age: _____ Phone Number: _________________________ Language: ____________________________
Household Contact: Yes No Notified: Yes No
Comments (i.e. relationship, any information caller will need): ________________________________________________________
__________________________________________________________________________________________________________
Close Contact #10:
Last Name: _______________________ First Name: ____________________ Date of Last Exposure: ______________
DOB:__________ Age: _____ Phone Number: _________________________ Language: ____________________________
Household Contact: Yes No Notified: Yes No
Comments (i.e. relationship, any information caller will need): ________________________________________________________
__________________________________________________________________________________________________________
Close Contact #11:
Last Name: _______________________ First Name: ____________________ Date of Last Exposure: ______________
DOB:__________ Age: _____ Phone Number: _________________________ Language: ____________________________
Household Contact: Yes No Notified: Yes No
Comments (i.e. relationship, any information caller will need): ________________________________________________________
__________________________________________________________________________________________________________
Close Contact #12:
Last Name: _______________________ First Name: ____________________ Date of Last Exposure: ______________
DOB:__________ Age: _____ Phone Number: _________________________ Language: ____________________________
Household Contact: Yes No Notified: Yes No
Comments (i.e. relationship, any information caller will need):
Santa Clara County COVID-19 Confirmed Case Report FormRev 10.13.20
Close Contact #13:
Last Name: _______________________ First Name: ____________________ Date of Last Exposure: ______________
DOB:___________ Age: _____ Phone Number: _________________________ Language: ____________________________
Household Contact: Yes No Notified: Yes No
Comments (i.e. relationship, any information caller will need): ________________________________________________________
__________________________________________________________________________________________________________
Close Contact #14:
Last Name: _______________________ First Name: ____________________ Date of Last Exposure: ______________
DOB:___________ Age: _____ Phone Number: _________________________ Language: ____________________________
Household Contact: Yes No Notified: Yes No
Comments (i.e. relationship, any information caller will need): ________________________________________________________
__________________________________________________________________________________________________________
Close Contact #15:
Last Name: _______________________ First Name: ____________________ Date of Last Exposure: ______________
DOB:___________ Age: _____ Phone Number: _________________________ Language: ____________________________
Household Contact: Yes No Notified: Yes No
Comments (i.e. relationship, any information caller will need): ________________________________________________________
__________________________________________________________________________________________________________
Close Contact #16:
Last Name: _______________________ First Name: ____________________ Date of Last Exposure: ______________
DOB:___________ Age: _____ Phone Number: _________________________ Language: ____________________________
Household Contact: Yes No Notified: Yes No
Comments (i.e. relationship, any information caller will need): ________________________________________________________
__________________________________________________________________________________________________________
Close Contact #17:
Last Name: _______________________ First Name: ____________________ Date of Last Exposure: ______________
DOB:___________ Age: _____ Phone Number: _________________________ Language: ____________________________
Household Contact: Yes No Notified: Yes No
Comments (i.e. relationship, any information caller will need): ________________________________________________________
__________________________________________________________________________________________________________
Close Contact #18:
Last Name: _______________________ First Name: ____________________ Date of Last Exposure: ______________
DOB:___________ Age: _____ Phone Number: _________________________ Language: ____________________________
Household Contact: Yes No Notified: Yes No
Comments (i.e. relationship, any information caller will need): ________________________________________________________
__________________________________________________________________________________________________________
Close Contact #19:
Last Name: _______________________ First Name: ____________________ Date of Last Exposure: ______________
DOB:___________ Age: _____ Phone Number: _________________________ Language: ____________________________
Household Contact: Yes No Notified: Yes No
Comments (i.e. relationship, any information caller will need): ________________________________________________________
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