Fillable Santa Clara County COVID-19 Case Report Form (For

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Santa Clara County COVID-19 Case Report Form (For

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Santa Clara County COVID-19 Confirmed Case Report Form– Rev 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 Form– Rev 10.13.20
Santa Clara County COVID-19 Confirmed Case Report Form– Rev 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 Form– Rev 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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Completed 13 November 2020

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