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:
□ Pregnancy (trimester: ______________)
□ Post-partum (< 6 weeks)
Cardiovascular disease, including hypertension
Immunodeficiency, including HIV
□ Diabetes
Renal disease
□ Liver disease
□ Chronic lung disease
Chronic neurological or neuromuscular disease
Malignancy
□ Other(s), please specify:
2
Health Status at time of reporting:
Admission to hospital: □ No □ Yes Unknown
First date of admission to hospital: [_D_][_D_]/[_M_][_M_]/[_Y_][_Y_][_Y_][_Y_]
If yes
Did the case receive care in an intensive care unit (ICU)? □ No □ Yes Unknown
Did the case receive ventilation? □ No □ Yes Unknown
Did the case receive extracorporeal membrane oxygenation? □ No □ Yes Unknown
Is case in isolation with Infection Control Practice in place □ No □ Yes Unknown
Date of isolation: [_D_][_D_]/[_M_][_M_]/[_Y_][_Y_][_Y_][_Y_]
Section 3: Exposure risk in the 14 days prior to symptom onset (prior to testing if asymptomatic)
Is case a Health Care Worker (any job in a health care setting): □ No □ Yes □ Unknown
If yes, Country: ____________________ City: ____________________ Name of Facility: _______________________________________
Has the case travelled in the 14 days prior to symptom onset? □ No □ Yes □ Unknown
If yes, please specify the places the patient travelled to and date of departure from the places:
Country
City
1.
Country ________________________________
City ________________________________
2.
Country ________________________________
City ________________________________
3.
Country ________________________________
City ________________________________
Has case visited any health care facility in the 14 days prior to symptom onset? □ No □ Yes Unknown
Has case had contact with a confirmed case in the 14 days prior to symptom onset? □ No □ Yes Unknown
If yes, please list unique case identifiers of all probable or confirmed cases:
If yes, please explain contact setting: _____________________________________________________________________________________
____________________________________________________________________________________________________________________________
Contact ID
First Date of Contact
1.
________________________________
Date ________________________________
2.
________________________________
Date ________________________________
3
________________________________
Date ________________________________
4
________________________________
Date ________________________________
5
________________________________
Date ________________________________
Most likely country of exposure: _______________________________________________________________________________________
Section 4: Outcome : complete and re-sent the full form as soon as outcome of disease is known or after
30 days after initial report
Date of re-submission of this report: [_D_][_D_]/[_M_][_M_]/[_Y_][_Y_][_Y_][_Y_]
If case was asymptomatic at time of specimen collection resulting in first laboratory confirmation, did the case develop any
symptoms or signs at any time prior to discharge or death:
□ No (i.e., case remains asymptomatic)
□ Yes, asymptomatic case (as previously reported ) developed symptoms and/or signs of illness
If yes, date of onset of symptoms/signs of illness: [_D_][_D_]/[_M_][_M_]/[_Y_][_Y_][_Y_][_Y_]
Unknown
Clinical Course:
Admission to hospital (may have been previously reported): □ No □ Yes Unknown
If admitted to hospital:
First date of admission to hospital: [_D_][_D_]/[_M_][_M_]/[_Y_][_Y_][_Y_][_Y_]
Did the case receive care in an intensive care unit (ICU)? □ No □ Yes Unknown
Did the case receive ventilation? □ No □ Yes Unknown
Did the case receive extracorporeal membrane oxygenation? □ No □ Yes Unknown
Health Outcome: Recovered/Healthy Not recovered Death Unknown: Other:
If other, please explain: ______________________________________________________________________________________
Date of Release from isolation/hospital or Date of Death: [_D_][_D_]/[_M_][_M_]/[_Y_][_Y_][_Y_][_Y_]
If released from hospital /isolation, date of last laboratory test:
[_D_][_D_]/[_M][_M_]/[_Y_][_Y_][_Y_][_Y_]
Results of last test: positive negative Unknown
Total number of contacts followed for this case: _____________ Unknown
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