CDC 2019-nCoV ID: Form Approved: OMB: 0920-1011 Exp. 4/23/2020
……………PATIENT IDENTIFIER INFORMATION IS NOT TRANSMITTED TO CDC……………………
Patient first name _______________ Patient last name __________________ Date of birth (MM/DD/YYYY): ____/_____/_______
……………PATIENT IDENTIFIER INFORMATION IS NOT TRANSMITTED TO CDC……………………
Human Infection with 2019 Novel Coronavirus
Person Under Investigation (PUI) and Case Report Form
Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information
including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011).
Reporting jurisdiction: ______________ Case state/local ID: ______________
Reporting health department: ______________ CDC 2019-nCoV ID: ______________
Contact ID
a
: ______________ NNDSS loc. rec. ID/Case ID
b
: ______________
a. Only complete if case-patient is a known contact of prior source case-patient. Assign Contact ID using CDC 2019-nCoV ID and sequential contact ID, e.g., Confirmed case CA102034567 has contacts CA102034567 -01 and
CA102034567 -02.
b
For NNDSS reporters, use GenV2 or NETSS patient identifier.
Interviewer information
Name of interviewer: Last ______________________________ First______________________________________
Affiliation/Organization: _______________________________ Telephone ________________ Email ______________________________
Basic information
What is the current status of this person?
PUI, testing pending*
PUI, tested negative*
Presumptive case (positive local test),
confirmatory testing pending
Presumptive case (positive local test),
confirmatory tested negative
Laboratory-confirmed case
*Testing performed by state, local, or CDC lab.
At this time, all confirmatory testing occurs at CDC
Report date of PUI to CDC (MM/DD/YYYY):
____/_____/_______
Report date of case to CDC (MM/DD/YYYY):
____/_____/_______
County of residence: ___________________
State of residence: ___________________
Ethnicity:
Hispanic/Latino
Non-Hispanic/
Latino
Not specified
Sex:
Male
Female
Unknown
Other
Date of first positive specimen
collection (MM/DD/YYYY):
____/_____/_______
Unknown N/A
Did the patient develop pneumonia?
Yes Unknown
No
Did the patient have acute
respiratory distress syndrome?
Yes Unknown
No
Did the patient have another
diagnosis/etiology for their illness?
Yes Unknown
No
Did the patient have an abnormal
chest X-ray?
Yes Unknown
No
Was the patient hospitalized?
Yes No Unknown
If yes, admission date 1
___/___/___ (MM/DD/YYYY)
If yes, discharge date 1
__/___/____ (MM/DD/YYYY)
Was the patient admitted to an intensive
care unit (ICU)?
Yes No Unknown
Did the patient receive mechanical
ventilation (MV)/intubation?
Yes No Unknown
If yes, total days with MV (days)
_______________
Did the patient receive ECMO?
Yes No Unknown
Did the patient die as a result of this illness?
Yes No Unknown
Date of death (MM/DD/YYYY):
____/_____/_______
Unknown date of death
Race (check all that apply):
Asian American Indian/Alaska Native
Black Native Hawaiian/Other Pacific Islander
White Unknown
Other, specify: _________________
Date of birth (MM/DD/YYYY): ____/_____/_______
Age: ____________
Age units(yr/mo/day): ________________
If symptomatic, onset date
(MM/DD/YYYY):
____/_____/_______
Unknown
If symptomatic, date of symptom resolution (MM/DD/YYYY):
____/_____/_____
Still symptomatic Unknown symptom status
Symptoms resolved, unknown date
Is the patient a health care worker in the United States? Yes No Unknown
Does the patient have a history of being in a healthcare facility (as a patient, worker or visitor) in China? Yes No Unknown
In the 14 days prior to illness onset, did the patient have any of the following exposures (check all that apply):
Travel to Wuhan Community contact with another Exposure to a cluster of patients with severe acute lower
Travel to Hubei lab-confirmed COVID-19 case-patient respiratory distress of unknown etiology
Travel to mainland China Any healthcare contact with another Other, specify:____________________
Travel to other non-US country lab-confirmed COVID-19 case-patient Unknown
specify:_____________________ Patient Visitor HCW
Household contact with another lab- Animal exposure
confirmed COVID-19 case-patient
If the patient had contact with another COVID-19 case, was this person a U.S. case? Yes, nCoV ID of source case: _______________ No Unknown N/A
Under what process was the PUI or case first identified? (check all that apply): Clinical evaluation leading to PUI determination
Contact tracing of case patient Routine surveillance EpiX notification of travelers; if checked, DGMQID_______________
Unknown Other, specify:_________________
CDC 2019-nCoV ID: Form Approved: OMB: 0920-1011 Exp. 4/23/2020
Human Infection with 2019 Novel Coronavirus
Person Under Investigation (PUI) and Case Report Form
Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information
including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011). 2
Symptoms, clinical course, past medical history and social history
Collected from (check all that apply): Patient interview Medical record review
Pre-existing medical conditions? Yes No Unknown
Chronic Lung Disease (asthma/emphysema/COPD)
Yes
No
Unknown
Diabetes Mellitus
Yes
No
Unknown
Cardiovascular disease
Yes
No
Unknown
Chronic Renal disease
Yes
No
Unknown
Chronic Liver disease
Yes
No
Unknown
Immunocompromised Condition
Yes
No
Unknown
Neurologic/neurodevelopmental/intellectual
disability
Yes
No
Unknown
(If YES, specify)
Other chronic diseases
Yes
No
Unknown
(If YES, specify)
If female, currently pregnant
Yes
No
Unknown
Current smoker
Yes
No
Unknown
Former smoker
Yes
No
Unknown
Respiratory Diagnostic Testing Specimens for COVID-19 Testing
Additional State/local Specimen IDs: ______________ ______________ ______________ ______________ ______________
During this illness, did the patient experience any of the following symptoms?
Symptom Present?
Fever >100.4F (38C)
c
Yes No Unk
Subjective fever (felt feverish)
Yes No Unk
Chills
Yes No Unk
Muscle aches (myalgia)
Yes No Unk
Runny nose (rhinorrhea)
Yes No Unk
Sore throat
Yes No Unk
Cough (new onset or worsening of chronic cough)
Yes No Unk
Shortness of breath (dyspnea)
Yes No Unk
Nausea or vomiting
Yes No Unk
Headache
Yes No Unk
Abdominal pain
Yes No Unk
Diarrhea (≥3 loose/looser than normal stools/24hr period)
Yes No Unk
Other, specify:_____________________________________________
Test
Pos
Neg
Pend.
Not
done
Specimen
Type
Specimen
ID
Date
Collected
State Lab
Tested
State Lab
Result
Sent to
CDC
CDC Lab
Result
Influenza rapid Ag A B
NP Swab
Influenza PCR A B
OP Swab
RSV
Sputum
H. metapneumovirus
Other,
Parainfluenza (1-4)
Specify:
Adenovirus
_________
Rhinovirus/enterovirus
Coronavirus (OC43, 229E,
HKU1, NL63)
M. pneumoniae
C. pneumoniae
Other, Specify:_________
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome