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
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. bFor 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? Ethnicity: Date of first positive specimen Was the patient hospitalized?
Patient under investigation (PUI) Hispanic/Latino collection (MM/DD/YYYY): Yes No Unknown
Laboratory-confirmed case Non-Hispanic/ ____/_____/_______
Latino Unknown N/A If yes, admission date 1
Report date of PUI to CDC (MM/DD/YYYY): Not specified ___/___/___ (MM/DD/YYYY)
____/_____/_______ Did the patient develop pneumonia? If yes, discharge date 1
Sex: Yes Unknown __/___/____ (MM/DD/YYYY)
Report date of case to CDC (MM/DD/YYYY): Male No
____/_____/_______ Female Was the patient admitted to an
Unknown Did the patient have acute intensive care unit (ICU)?
County of residence: ___________________ Other respiratory distress syndrome? Yes No Unknown
State of residence: ___________________ Yes Unknown
Race (check all that apply): No Did the patient receive mechanical
ventilation (MV)/intubation?
Asian American Indian/Alaska Native Did the patient have another Yes No Unknown
Black Native Hawaiian/Other Pacific Islander diagnosis/etiology for their illness? If yes, total days with MV (days)
White Unknown Yes Unknown _______________
No
Other, specify: _________________
Did the patient receive ECMO?
Date of birth (MM/DD/YYYY): ____/_____/_______ Did the patient have an abnormal Yes No Unknown
Age: ____________ chest X-ray?
Age units(yr/mo/day): ________________ Yes Unknown Did the patient die as a result of this
No illness?
Yes No Unknown
Symptoms present If symptomatic, onset If symptomatic, date of symptom resolution (MM/DD/YYYY):
during course of illness: date (MM/DD/YYYY): ____/_____/_____ Date of death (MM/DD/YYYY):
Symptomatic ____/_____/_______ Still symptomatic Unknown symptom status ____/_____/_______
Asymptomatic Unknown Symptoms resolved, unknown date Unknown date of death
Unknown
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:_________________

Symptoms, clinical course, past medical history and social history

Collected from (check all that apply): Patient interview Medical record review

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).
 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
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:_____________________________________________ -
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 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

Test Pos Neg Pend. Not done Specimen Specimen Date Sent to State Lab
Type ID Collected CDC Tested
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:__________________ - - - -

Additional State/local Specimen IDs: ______________ ______________ ______________ ______________ ______________

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).
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