Fillable Florida Health Coronavirus Disease 2019 (COVID-19) Interim Person Screening Form

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Florida Health Coronavirus Disease 2019 (COVID-19) Interim Person Screening Form

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Coronavirus Disease 2019 (COVID-19)
Interim Person Screening Form
Updated 3/20/2020 Page 1 of 4
This form may be used by county health departments for persons under investigation (PUI) for possible patients who meet the
definition of a COVID-19 PUI. Please create a case in Merlin for each PUI identified. If you have questions after hours, contact the
Florida Department of Health Bureau of Epidemiology at 850-245-4401.
Contact Information use date format: (MM/DD/YY)
Merlin Case ID
CDC PUI Number
New Report Update to previous report
Date CHD Notified
Report Date
( / / )
( / / )
Reporting County
Interviewer Phone
Interviewer Email
Person Name (Last, First, M.I.):
Parent/Guardian Name (if Minor)
Person or Guardian Phone
Person Address: Number, Street, Apt #
City
County
State
ZIP Code
Person lives in a group setting Yes No
Group setting type ALF Nursing home LTCF Correctional Other: ____________
Group setting name
Group setting address
Reporting Facility (Hospital) Name
Reporting Facility Phone
IP’s Name
Physician’s Name
Reporting Facility Address
City
County
State
ZIP Code
How person was identified (check one)
Clinician notified CHD Unusual lab result Ill traveler identified coming/returning to the US Other: ________
Demographic Information use date format: (MM/DD/YY)
Date of Birth ( / / )
Age
Sex Male Female Other Unk
Race (check one)
African-American/Black Asian/Pacific Islander
Native American White Other: ________________
Ethnicity (check one)
Hispanic/Latino Non-Hispanic Unk
Usual Occupation
Industry
Does the person have any close contacts
1
?
Yes No Unk
Symptoms, Treatment use date format: (MM/DD/YY)
Illness onset date ( / / )
Person was symptomatic
at initial interview
Yes No, date person felt back to normal: ( / / )
Unk
Primary symptoms person has experienced during illness:
Fever
Yes No Unk
Onset date ( / / )
Measured, highest temp: ____ Subjective
Dry cough
Yes No Unk
Onset date ( / / )
Productive cough
Yes No Unk
Onset date ( / / )
Shortness of
breath/dyspnea
Yes No Unk
Onset date ( / / )
Check all additional symptoms that the person has experienced during illness and include date of onset:
Sore throat ( / / )
Headache ( / / )
Chills ( / / )
Muscle aches ( / / )
Nausea/vomiting ( / / )
Abdominal pain ( / / )
Diarrhea ( / / )
Runny nose/rhinorrhea ( / / )
Other, specify:_________ ( / / )
dd mmm yyyy
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dd mmm yyyy
dd mmm yyyy
dd mmm yyyy
dd mmm yyyy
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dd mmm yyyy
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Coronavirus Disease 2019 (COVID-19)
Interim Person Screening Form
Updated 3/20/2020 Page 2 of 4
Check all diagnoses person has received and include date of diagnosis:
Pneumonia ( / / )
ARDS ( / / )
Renal Failure ( / / )
Abnormal chest X-ray ( / / )
Other, specify: ___________ ( / / )
Check all underlying health conditions of the person:
Diabetes
Chronic Lung Disease
Chronic Kidney Disease
Chronic Liver Disease
Cardiac Disease
Hypertension
Immunocompromised, specify:
___________________________
Neurologic/neurodevelopmental,
specify: ______________________
Other, specify:
___________
Person is pregnant
Yes No Unk
Current smoker
Yes No Unk
Former smoker
Yes No Unk
Patient has a non-COVID-19 etiology for their respiratory
illness but has not responded to appropriate therapy
Yes, specify: _________________ No Unk
Specify locations where person sought medical care for their illness:
Location
Earliest date
(MM/DD/YY)
Details
Doctor’s Office
Health Department
Urgent Care Clinic
Emergency Department
Other
Unknown
Was person hospitalized for this illness?
Yes, date of admission ( / / ) No Unk
Did person die as a result of this illness?
Yes, date of death ( / / ) No Unk
Risk Factors
In the 14 days before symptom onset:
Person traveled to or from geographic region
with sustained community transmission
Yes No Unk
Destinations and dates including arrival to the US
Person had travel companions
Yes No Unk
Names and phone numbers of travel companions
Person traveled to or from mainland China
Yes No Unk
Destinations and dates including arrival to the US
In China, person in a health care
facility as a patient, worker, or visitor
Yes No Unk
Dates and details of exposure
Patient is a health care worker in the US
Yes No Unk
dd mmm yyyy
dd mmm yyyy
dd mmm yyyy
dd mmm yyyy
dd mmm yyyy
dd mmm yyyy
dd mmm yyyy
Coronavirus Disease 2019 (COVID-19)
Interim Person Screening Form
Updated 3/20/2020 Page 3 of 4
Risk Factors
In the 14 days before symptom onset:
Person had close contact
1
with a laboratory-
confirmed COVID-19 case
Yes No Unk
Case was ill at time of contact
Yes No Unk
Case was reported
in US Outside US
If outside US, specify country
Types of contact:
Household contact
Yes No Unk
Community contact
Yes No Unk
Health care contact
Yes No Unk
Person status at time of health care contact with lab-confirmed COVID-19 case:
Patient
Yes No Unk
Visitor
Yes No Unk
Health care worker
Yes No Unk
Person is a member of a cluster of patients
with medically attended respiratory illness of
unknown etiology in which COVID-19 is
being evaluated in consultation with state and
local health departments
Yes No Unk
Person’s relationship to each cluster member
Person Contact
If hospitalized:
Patient is/was in a negative pressure room
Yes No Unk
Patient admitted to ICU
Yes No Unk
Patient is/was in a private room
Yes No Unk
Patient on ECMO
Yes No Unk
Patient received mechanical ventilation (MV)/intubation
Yes, total days with MV:_____ No Unk
PPE health care personnel used when
caring for patient or obtaining specimens
N95 Mask
Surgical mask
Facemask
Eye Protection
Gloves
Gown
None
Unk
At time of interview, person was currently at a health care facility
Yes No Unk
If yes:
Patient used surgical mask during transport within current health care facility
Yes No Unk
1
Close contact is defined as a) being within approximately 6 feet (2 meters), or within the room or care area, of a COVID-19 case for a prolonged period of time while not
wearing recommended personal protective equipment or PPE (e.g., gowns, gloves, NIOSH-certified disposable N95 respirator, eye protection); close contact can include
caring for, living with, visiting, or sharing a healthcare waiting area or room with a COVID-19 case; or b) having direct contact with infectious secretions of a COVID-19 case
(e.g., being coughed on) while not wearing recommended personal protective equipment. Data to inform the definition of close contact are limited. Considerations when
assessing close contact include the duration of exposure (e.g., longer exposure time likely increases exposure risk) and the clinical symptoms of the person with COVID-19
(e.g., coughing likely increases exposure risk as does exposure to a severely ill patient). Special consideration should be given to those exposed in health care settings.
Coronavirus Disease 2019 (COVID-19)
Interim Person Screening Form
Updated 3/20/2020 Page 4 of 4
Testing
Specify all non-COVID-19 testing performed:
Test Type
Specimen Collection
Date (MM/DD/YY)
Result
Influenza: Rapid test
A B Positive Negative
Pending Other: _________
Influenza: PCR
A B Positive Negative
Pending Other: _________
Influenza: Other test
A B Positive Negative
Pending Other: _________
Respiratory syncytial virus
Positive Negative Pending
Human metapneumovirus
Positive Negative Pending
Adenovirus
Positive Negative Pending
Parainfluenza 1-4
Positive Negative Pending
Rhinovirus/enterovirus
Positive Negative Pending
Coronavirus (OC43, 229E, HKU1, NL63)
Positive Negative Pending
Legionella pneumophila
Positive Negative Pending
Streptococcus pneumoniae
Positive Negative Pending
Mycoplasma pneumoniae
Positive Negative Pending
Chlamydia pneumoniae
Positive Negative Pending
Other: _______________
Positive Negative Pending
Blood culture
Specify organisms
Specify all specimens collected for COVID-19 testing:
Specimen
Collection Date
(MM/DD/YY)
Sent to BPHL
Sputum
Yes No
Tracheal aspirate (TA)
Yes No
Bronchial alveolar lavage (BAL)
Yes No
Nasopharyngeal (NP)
Yes No
Oropharyngeal (OP)
Yes No
Serum
Yes No
Stool
Yes No
Urine
Yes No
Other: ____________
Yes No
Other Notes
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Florida Health Coronavirus Disease 2019 (COVID-19) Interim Person Screening Form

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Completed 26 March 2020

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