Revised case report form for Confirmed Novel Coronavirus COVID-19
(report to WHO within 48 hours of case identification)
Date of reporting to national health authority: [_D_][_D_]/[_M_][_M_]/[_Y_][_Y_][_Y_][_Y_]
Reporting country: _______________________________
Why tested for COVID-19:
□ Contact of a case □ Ill Seeking Healthcare due to suspicion of COVID-19 □ Detected at point of entry □ Repatriation
□ Routine respiratory disease surveillance systems (e.g influenza) □ Unknown
If none of the above, please explain: ______________________________________________________________________________________
Section 1: Patient information
Unique Case Identifier (used in country): _____________________________
Age (years): [___][___][___] if <1 year old, [___][___] in months or if < 1 month, [___][___] in days
Sex at birth: □ Male □ Female
Place where the case was diagnosed: Country: ______________________________
Admin Level 1 (province): _______________________________
Case usual place of residency: Country: ______________________________
Section 2: Clinical Status
Date of first laboratory confirmation test: [_D_][_D_]/[_M_][_M_]/[_Y_][_Y_][_Y_][_Y_]
Any symptoms* or signs at time of specimen collection that resulted in first laboratory confirmation?
□ No (i.e., asymptomatic) □ Yes □ Unknown
If yes, date of onset of symptoms: [_D_][_D_]/[_M_][_M_]/[_Y_][_Y_][_Y_][_Y_]
Underlying conditions and comorbidity:
Any underlying conditions? □ No □ Yes □ Unknown
If yes, please check all that apply: