Form and checklist for confirmed COVID-19 patients · COVID-19 Confirmed Case Investigation Worksheet . History of Activity 2 Days Before and 7 Days After Symptom Onset Instructions:

Page of v.05/18/2020 Provider Signature Date

Form and checklist for confirmed COVID-19 patients Sec PRV

Prim PRV

Name of investigator: Date test result received:

Name of patient: DOB:_____________ Gender: _______

CDC ID number: NBS number:

Minors: Guardian Name: Guardian Job Status: Employed Unemployed Retired

Address:

Phone number(s): Email:

Date and approximate time of symptom onset: Infectious period start date: (Onset – 2 days)

Initial symptoms:

Contact with a known case of COVID-19: Yes □ No □ Name:

Recent travel history? Yes □ No □ Location and date(s):

Recent contact with any visitors from another location? Yes □ No □ Location and date(s):

Patient reside in a congregate or LTCF? Yes □ No □ Name, address:

Does the patient have a thermometer? Yes □ No □ Does the patient have a mask? Yes □ No □

Last date of patient’s isolation (a.k.a. infectious period end date): Persons with COVID-19 who have symptoms and were directed to care for themselves at home may discontinue home isolation under the following conditions:

At least3 days (72 hours)have passed since recovery defined as resolution of fever without the useof fever- reducing medications and improvement in respiratory symptoms (e.g., cough, shortness ofbreath); AND

At least 10 days have passed since symptoms first appeared.

The following steps for each patient should be complete. Check-off when completed.

□ Verify that hcp notified patient of test result□ Request medical records and patient demographic information from health care facility as needed□ Advise healthcare facilities where patient was seen to review infection control surrounding visit□ If applicable, patient advised on home isolation□ Interview patient□ If applicable, complete source investigation□ Contacts interviewed and emailed information□ Complete CDC PUI and Case Report Form as much as possible (prioritize variables on the first page) and

return to Epi. For instructions for completing the case report form visit: https://www.cdc.gov/coronavirus/2019-ncov/downloads/COVID-19-Persons-Under-Investigation-and-Case-Report-Form-Instructions.pdf

□ When available, send EPI contact line list with names, DOBs, and risk level□ Contact line list returned to Epi indicating that contacts have cleared from quarantine□ Patient provided with release from isolation letter, and last date of patient’s isolation forwarded to Epi

CL 45 TP Code 01 02 07 30 TP Code EPSDT 547 EPI Investigation 04 Group Services 19

AT TT Medicaid # (V01.79)

Health Center HR#

POV Counsel POS COVID-19

Other POV

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tssteenhoutSticky NoteAccepted set by tssteenhout

Human Infection with Coronavirus Disease 2019 (COVID-19) Surveillance Worksheet

NAME ADDRESS (Street and No.) PHONE Hospital Record No. ________________________ ___________________ _________________________________ __________________ ____________________ (last) (first)

This information will not be sent to CDC

REPORTING SOURCE TYPE NAME _______________________ _______________________ PH clinic ADDRESS ם physician ם ______________________ laboratory ZIP CODE ם nurse ם __ __ __ __ __ __ __ (__ __ __) other clinic PHONE ם hospital ם _______________________________________ other source type ם

LOCAL SUBJECT ID __________________________________

SUBJECT ADDRESS STATE __________________________________

SUBJECT ADDRESS COUNTY __________________________

SUBJECT ADDRESS ZIP CODE ___ ___ ___ ___ ___

CASE INFORMATION NNDSS ID ______________ (Local Record/Case ID)

Date of Birth __ __ __ __ __ __ __ __ month day year

Country of Birth ___________ Other Birthplace ______________

Ethnic Group H=Hispanic/Latino N=Not Hispanic/Latino O=Other ______________ U=Unknown Country of Usual Residence ______ Race American Indian/Alaskan Native ם Asian ם Unknown ם ________Otherם Refused to answer ם םWhite edNot askם Native Hawaiian/Pacific Islanderם Black/African American ם

Sex M=male F=female U=unknown Age at Case Investigation _____ Age Unit* ____ Date Reported __ __ __ __ __ __ __ __ month day year

Reporting State ____ Earliest Date Reported to State __ __ __ __ __ __ __ __ month day year

Date First Reported to PHD __ __ __ __ __ __ __ __ month day year

Reporting County _______ Earliest Date Reported to County __ __ __ __ __ __ __ __ month day year

National Reporting Jurisdiction _______

CDC 2019-nCOV ID _______________ Date First __ __ __ __ __ __ __ __ Positive Specimen (mm/dd/yyyy)

If probable case, reason for case classification:

Case Investigation __ __ __ __ __ __ __ __ Start Date month day year

CASE

CLASS

STATUS

Confirmed ם Unknown ם Probable ם Not a case ם Suspected ם

Meets clinical criteria AND epidemiologic evidence with no confirmatory lab testing performed for COVID-19

Meets presumptive lab evidence AND either clinical criteria OR epidemiologic evidence

Meets vital records criteria with no confirmatory lab testing

DGMQID _____________________ [If Epi-X notification of travelers checked, DGMQID]

DETECTION METHOD

Autopsy Laboratory reported Other method (specify below) Clinical evaluation Provider reported ___________________________ Contact tracing of case patient Routine physical examination ___________________________ Epi-X notification of travelers Routine surveillance Unknown

HOSPITALIZATION INFORMATION

Illness Onset Date __ __ __ __ __ __ __ __ month day year

Illness End Date __ __ __ __ __ __ __ __ month day year

Illness Duration _____ Duration Units* ______

Hospitalized? Y=yes N=no U=unknown Hospital Admission Date __ __ __ __ __ __ __ __ month day year

Hospital Discharge Date __ __ __ __ __ __ __ __ month day year

Duration of Hospital Stay 0 – 998 __________ 999=unknown (days) Patient admitted to an Intensive Care Unit (ICU)? Y=yes N=no U=unknown

If hospitalized, was a translator/Interpreter required? Y=yes N=no U=unknown ICU Admission Date __ __ __ __ __ __ __ __ month day year

If a translator was required, specify the patient's primary language: ______ ICU Discharge Date __ __ __ __ __ __ __ __ month day year

Pregnant at time of event? Y=yes N=no U=unknown If yes, trimester at illness onset: Number Weeks Gestation

Did subject die from illness/complications of illness? Y=yes N=no U=unknown Date of Death __ __ __ __ __ __ __ __ month day year *UNITS a=year d=day h=hour min=minute mo=month s=second wk=week UNK=unknown

JAN 2021 Page 1 of 5

CLINICAL INFORMATION

INFORMATION SOURCE for CLINICAL DATA

Medical records Patient interview Unknown DATE of DIAGNOSIS

__ __ __ __ __ __ __ __ month day year

Other (specify) ___________________________________________

Symptoms present during course of illness? Y=yes N=no U=unknown Did symptom(s) resolve? Y=yes N=no U=unknown

Symptom __ __ __ __ __ __ __ __ Onset Date month day year

Symptom __ __ __ __ __ __ __ __ Resolution Date month day year

Secondary Diagnosis? Y=yes N=no U=unknown (if yes, specify) __________________________________

SIGNS and SYMPTOMS

Y N U [Y=yes] Y N U [N=no] Y N U [U=unknown] Abdominal pain Subjective fever Runny nose Chest pain Fever >100.4F (38C) Sore throat Chills Headache Vomiting Cough Nausea Wheezing Diarrhea New olfactory disorder Other (specify) ____________ Difficulty breathing New taste disorder _________________________ Dyspnea Muscle aches _________________________ Fatigue Rigors Unknown

CLINICAL FINDINGS

Y N U NA [Y=yes; N=no; U=unknown] Y N U NA [NA=not applicable] Acute respiratory distress syndrome (ARDS) Other (specify) ___________________ Abnormal EKG Pneumonia Abnormal chest x-ray Unknown

TREATMENT TYPE

Y N U [Y=yes; N=no; U=unknown] DURATION (days) Y N U DURATION (days) Mechanical ventilation/intubation Other (specify) ______ ECMO Unknown

Did patient have underlying medical conditions and/or risk behaviors? Y=yes N=no U=unknown Provide response for each below: Underlying Conditions or Risk Factors [Y=yes; N=no; U=unknown] Y N U Y N U Y N U Y N U

Autoimmune condition Current smoker Hypertension Psychological/psychiatric‡

Cardiovascular disease Diabetes mellitus Immunosuppressive condition Severe obesity (BMI ≥40)

Chronic liver disease Disability† Other chronic disease Substance abuse

Chronic lung disease Former smoker Other (specify) ______________ Unknown

Chronic renal disease †If disability, type _____________________ ‡If mental condition, type ___________________

DEMOGRAPHIC INFORMATION

Tribal affiliation? Y=yes N=no U=unknown Tribal Name ___________ Enrolled Tribe Name ___________

RESIDENCE at ILLNESS

ONSET

Acute care inpatient facility Homeless shelter Long term care facility Other (specify) _________________ Apartment Hotel Mobile home Outside Assisted living facility House/single family Motel Rehabilitation facility Correctional facility Group home Nursing home Unknown

Was case-patient a healthcare personnel (HCP) at time of illness onset? Y=yes N=no U=unknown If yes, select from below:

HCP OCCUPATION

TYPE

Environmental services Nurse HCP

WORKPLACE SETTING

Assisted living facility Hospital

Respiratory therapist Physician Long term care facility Nursing home

Other Unknown Rehabilitation facility Unknown

Other (specify) ___________________________

Page 2 of 5

EXPOSURE and IMPORTATION INFORMATION In the 14 days prior to illness onset, did the patient have any of the following exposures: (check all that apply)

Y N U [Y=yes, N=no, U=unknown] Y N U Y N U Airport/Airplane Other (specify)

International travel

Adult congregate living facility Correctional facility School/university

Childcare facility Domestic travel

Community event/mass gathering Unknown exposures in the 14 days prior to illness onset

Animal (confirmed/suspected COVID-19) Animal Type ______________________________________________________________

Workplace Workplace critical infrastructure? Setting (specify) ____________________

Cruise ship or vessel travel as

Name of ship(s) 1) __________________________ 2) ___________________________

Contact with confirmed/probable COVID-19 case: community healthcare associated household other __________ unknown

If contact with COVID-19 case, was this person a U.S. case? Linked Case Number ___________________________

TRAVEL

HISTORY

International Destinations

Country Departure Date (mm/dd/yyyy) Return Date (mm/dd/yyyy) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Domestic Destinations

State Departure Date (mm/dd/yyyy) Return Date (mm/dd/yyyy)

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

CASE DISEASE IMPORTED CODE

Indigenous In state, out of jurisdiction Out of state

International Unknown Yes, imported, but not able to determine source state/country

Imported Country ____________ Imported State _________ Imported County ______________ Imported City ___________________

Country of Exposure _______________________________________ State or Province of Exposure __________________________________ County of Exposure ________________________________________ City of Exposure ____________________________________________ Outbreak related? Y=yes N=no U=unknown Outbreak Name

Transmission Mode __ __ __ __ __ __ __ __ __

ALABORATORY INFORMATION

Test Type

Test Result

Result Units

Test Result Quantitative

Date Specimen Collected

mm dd yyyy

Specimen Type

Performing Laboratory

Specimen ID

Performing Laboratory

Type

TEST RESULT Q=Equivocal result E=Indeterminate

N=Negative NS=No significant rise in IgG

X=Not done OTH=Other (specify)

I=Pending P=Positive

S=significant rise in IgG UNK=Unknown

U=Unsatisfactory V=Vaccine type strain

W=Wild type strain

SPECIMEN TYPE 1 Bacterial isolate 9 CSF 17 NP swab 25 Saliva 33 Swab 41 Vesicle fluid 2 Blood 10 Crust 18 NP washing 26 Scab 34 Swab, skin lesion 42 Viral isolate 3 Body fluid 11 DNA 19 Nucleic acid 27 Serum 35 Swab, nasal sinus 43 Other 4 BAL 12 Dried blood 20 Oral fluid 28 Skin lesion 36 Swab, vesicular 44 Unknown 5 Buccal smear 13 Lesion 21 Oral swab 29 Specimen 37 Swab, internal nose 6 Buccal swab 14 Macular scraping 22 Plasma 30 Lung (BAL wash) 38 Throat swab 7 Capillary blood 15 Microbial isolate 23 Respiratory 31 Lavage 39 Tissue 8 Cataract 16 NP aspirate 24 RNA 32 Stool 40 Urine

PERFORMING LABORATORY TYPE

1=CDC lab 2=commercial lab 3=hospital lab 4=other 5=other clinical lab 6=public health lab 7=unknown 8=VPD testing lab

Page 3 of 5

VACCINATION HISTORY INFORMATION

Vaccinated (has the case-patient ever received a vaccine against this disease)? Y=yes N=no U=unknown

Number of doses against this disease received prior to illness onset? 0–6 99=unknown (doses)

Date of last vaccine dose against this disease prior to illness onset? __ __ __ __ __ __ __ __ (mm/dd/yyyy)

Was the case-patient vaccinated as recommended by the ACIP? Y=yes N=no U=unknown

Vaccine Type

Vaccination Date month day year

Vaccine Manuf

Vaccine Lot No.

National Drug Code

Vaccine Expiration Date

month day year

Vaccination Record

Identifier

Vaccine Event Information

Source

Vaccine Dose

Number

_______

_______

_______

_______

_______ _______

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

_____

_____

_____

_____

_____

_____

__________ __________ __________ __________ __________ __________

__________ __________ __________ __________ __________ __________

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __

____________

____________

___________

____________

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____________

_____

_____

_____

_____

_____

_____

_____

_____

_____

_____

_____

_____

Vaccine Type

207=COVID-19, mRNA, LNP-S, PF, 100 mcg/0.5 mL dose 208=COVID-19, mRNA, LNP-S, PF, 30 mcg/0.3 mL dose 210=COVID-19, vector-nr, rS-ChAdOx1, PF, 0.5 mL dose 213=SARS-COV-2 (COVID-19) UNSPECIFIED OTH=other

Vaccine Event Information Codes 00=New immunization record 05=Other registy (historical) 08=Public agency (historical) 01=Unspecified source 06=Birth certificate (historical) OTH=Other 02=Other provider (historical) 07=School record (historical) UNK=Unknown PHC1435=Patient/parent recall (historical) PHC1436=Patient/parent written record PHC1936=Immunization Information System PP=Primary care provider 184225006=Medical record

Vaccine Manufacturer PFR=Pfizer MOD=Moderna US

Reason Not Vaccinated Per ACIP 1=religious exemption 5=MD diagnosis of previous disease 9=unknown 13=parent/patient unaware of recommendation 2=medical contraindication 6=too young 10=parent/patient forgot to vaccinate 14=missed opportunity 3=philosophical objection 7=parent/patient refusal 11=vaccine record incomplete/unavailable 15=foreign visitor 4=lab evidence of previous disease 8=other _______________ 12=parent/patient report of previous disease 16=immigrant

Vaccine History Comments

CASE NOTIFICATION

CONDITION CODE 11065 Immediate National Notifiable Condition Y=yes N=no U=unknown Date of First Verbal Notification to CDC __ __ __ __ __ __ __ __ month day year

Date of Electronic Case Notification to CDC __ __ __ __ __ __ __ __ month day year

State Case ID ______________ Legacy Case ID ________________ Date First Electonic Submission __ __ __ __ __ __ __ __ month day year

Notification Result Status Final results Correction Cannot obtain Jurisdiction Code _________________________

Binational Reporting Criteria ___ ___ ___ ___ ___ ___ ___ MMWR WEEK ___ MMWR YEAR ___ ______

Current Occupation (type of work patient does) ____________________________ Current Occupation Standardized (NIOCCS code) _________

Current Industry (type of business/industry in which patient works) _____________ Current Industry Standardized (NIOCCS code) _____________

Person Reporting to CDC ______________________ (first) NAME __________________________________ (last)

Person Reporting to CDC Email ________________ @ _________________ Person Reporting to CDC Phone Number (__ __ __) __ __ __ __ __ __ __

Comments

Page 4 of 5

https://wwwn.cdc.gov/nioccs3/https://wwwn.cdc.gov/nioccs3/

CLINICAL CASE DEFINITION§

Suspect Meets supportive laboratory evidence¶ with no prior history of being a confirmed or probable case.

Probable

Meets clinical criteria# AND epidemiologic linkage** with no confirmatory laboratory testing performed for SARS-C0V-2. Meets presumptive†† laboratory evidence. Meets vital records‡‡ criteria with no confirmatory laboratory testing performed for SARS-CoV2.

Confirmed Meets confirmatory§§ laboratory evidence.

¶Detection of specific antibody in serum, plasma, or whole blood Detection of specific antigen by immunocytochemistry in an autopsy specimen

[For suspect cases (positive serology only), jurisdictions may opt to place them in a registry for other epidemiological analyses or investigate to determine probable or confirmed status.]

_______________________________________________________________________ #In the absence of a more likely diagnosis:

• At least two of the following symptoms: fever (measured or subjective), chills, rigors, myalgia, headache, sore throat, nausea or vomiting, diarrhea, fatigue, congestion or runny nose, new olfactory disorder, new taste disorder

OR • Any one of the following symptoms: cough, shortness of breath, difficulty breathing OR • Severe respiratory illness with at least one of the following:

◦ Clinical or radiographic evidence of pneumonia, ◦ Acute respiratory distress syndrome (ARDS).

______________________________________________________________________

**One or more of the following exposures in the prior 14 days: • Close contact with a confirmed or probable case of COVID-19 disease; • Member of a risk cohort as defined by public health authorities during an outbreak. [Close contact is generally defined as being within 6 feet for at least 15 minutes. However, it depends on the exposure level and setting; for example, in the setting of an aerosol-generating procedure in healthcare settings without proper PPE, this may be defined as any duration. Data are insufficient to precisely define the duration of exposure that constitutes prolonged exposure and thus a close contact.

_____________________________________________________________

_____________________________________________________________________

______________________________________________________________________

††Detection of SARS CoV-2 by antigen test in a respiratory specimen.

‡‡A death certificate that lists COVID-19 disease or SARS-CoV-2 as an underlying cause of death or a significant condition contributing to death.

§§ Detection of SARS-CoV-2 RNA in a clinical or autopsy specimen using a molecular amplification test

§https://cdn.ymaws.com/www.cste.org/resource/resmgr/ps/positionstatement2020/Interim-20-ID-02_COVID-19.pdf

Page 5 of 5

https://cdn.ymaws.com/www.cste.org/resource/resmgr/ps/positionstatement2020/Interim-20-ID-02_COVID-19.pdf

Page of Provider Signature Date

COVID-19 Confirmed Case Investigation Worksheet

Patient Name (Last, First): CDC ID NUMBER: NBS (STATE) ID NUMBER:

Patient Date of Birth: Physical Address/Current Patient Location:

Current Sex: M F Phone:

Section of Epidemiology Infectious Disease Program | Phone 907-269-8000 | Fax 907-563-7868 | http://dhss.alaska.gov/dph/Epi/id/Pages/default.aspx Ver. 05/18/20

Epidemiologic Information

Does the patient attend day care*? Y N U If yes, specify name of facility, location, and phone number(if available): _

*Defined as a supervised group of 2 or more unrelated children for at least 4 hours per week

Does the patient reside in a congregate or long-term care facility? Y N U If yes, specify name of facility, location, and phone number(if available): _

Has the patient had recent travel history? Y N U If yes, specify location and date(s):

Has the patient had recent contact with any visitors from another village/city/state? Y N U If yes, specify location and date(s):

Is the patient a contact to a known lab-confirmed COVID-19 Case? Y N U

If yes, specify name, DOB, date(s) and nature of contact with confirmed case (if available): _

Physician: Reporting Hospital/Practice:

http://dhss.alaska.gov/dph/Epi/id/Pages/default.aspx


History of Activity 2 Days Before and 7 Days After Symptom Onset Instructions: include all locations that the patient may have visited outside their home for the period of interest. This includes daily activities like shopping, sports practice, work attendance and single events such as attendance at a party, fair, festival, etc. Please also ask about visitors to their home in this time frame. Use additional pages as needed to capture this information.

Day Date Activities

INFE

CT

IOU

S P

ER

IOD

-2

-1

0 (Illness onset)

1

2

3

4

5

6

7

8

9

10

Use additional pages as needed to capture this information

Completed by: Phone: Date:

Page of Section of Epidemiology Infectious Disease Program | Phone 907-269-8000 | Fax 907-563-7868 | http://dhss.alaska.gov/dph/Epi/id/Pages/default.aspx Ver. 05/18/20


Summary of Contacts


Page of

Name(s) of Investigator(s):

Name of index patient: DOB Gender

Please provide risk assessment and instructions given from each contact form. Use additional sheets as needed.

Risk assessment categories: C=Contact; GP=General Population

Instruction categories: Q=self-quarantine; OBS=self-observation

Name DOB Risk Assessment

Phone Number Type of Contact (work, household, etc.)

Instructions Date of Last Exposure

End of 14 day period(if

known)



CONTACT of confirmed case - (SOE 2019 COVID-19 PUI form PHN 4.27.2020) Sec PRV Prim PRV

Investigator Name: Interview date:

Name of contact: DOB: Gender:

Minors: Guardian Name:___________________ ___ Guardian Job Status: Employed Unemployed Retired

Address:

Phone number(s): Email:

Name of index case: Case Infectious period start date: (2 days before symptom onset)

Date of contact’s most recent exposure to index case while index case was infectious:

Nature of contact with the index case (Describe)

Household member Yes No Intimate partner Yes No

Individual providing care in the household without using recommended infection control precautions Yes No

Individual who had close contact (< 6 feet)** for a prolonged period of time (current definition >10 minutes) Yes No

Other (e.g., someone who was coughed on by case): Yes No If yes, describe?________________________

_________________________________________________________________________________________

• Is contact with the index case ongoing (e.g. household contact or caregiver)? Yes No

• Does the contact have current/recent (past 2 weeks) history of fever or respiratory symptoms? Yes No

• If symptomatic, was the contact referred for testing? Yes No

• Does the contact have a thermometer? Yes No

• Does the contact have a mask (to be worn if symptomatic)? Yes No

Remind all contacts to call ahead to a provider and tell the provider they are a contact before seeking care.

Risk Assessment (circle one): Contact (if yes to any of the questions in the ‘Nature of Contact box’ above)

General Population-level Risk

Instructions Given* (circle one): Self-quarantine/ General guidance

*Additional information will be needed for contacts who are health care providers.

Quarantine / monitoring period ends (14 days after last contact with index case) (NOTE: those with ongoing case may need to restart

their 14 days when the case is released from isolation.)

Contact cleared date (if known):_______________________________

Checklist: • Contact emailed / faxed information sheet: Yes No

• Information submitted to relevant PHN: Yes No

• Contact entered into NBS: Yes No

** Factors to consider when defining close contact include proximity, the duration of exposure (e.g., longer exposure time likely increases exposure risk), whether the case had symptoms (e.g., coughing likely increases exposure risk) and whether the individual was wearing a facemask (which can efficiently block respiratory secretions from contaminating others and the environment).

Page of Provider Signature Section of Epidemiology Infectious Disease Program | Phone 907-269-8000 | Fax 907-563-7868 | http://dhss.alaska.gov/dph/Epi/id/Pages/default.aspx Ver. 05/18/20

CL 45 TP Code 01 02 07 30 TP Code EPSDT 547 EPI Investigation 04 Group Services 19

AT TT Medicaid # (V01.79)

Health Center HR#

POV Counsel Contact COVID-19

Other POV

Insurance Type: ☐ Medicaid ☐ Medicare ☐ Tricare ☐ Other Private Insurance ☐ Uninsured/Tribal

Race (check all that apply): ☐ American Indian/Alaska Native ☐ Asian ☐ Black/African American ☐ Hawaiian/Pacific Islander ☐ White

Number in Household ________ - Household Income (before taxes) per month _____________ - Hispanic? ☐ Yes ☐ No


COVID-19 Confirmed Case Investigation Worksheet Page of Source Investigation To be completed if suspected community transmission

Days prior to symptom onset:

DAY Instructions include all locations that the patient may have visited outside their home for the period of interest. This includes daily activities like shopping, sports practice, work

attendance and single events such as attendance at a party, fair, festival, etc. Please ask about visitors to their home. Use additional pages as necessary.

-1

-2

-3

-4

-5

-6

-7

-8

-9

-10

-11

-12

-13

-14

Completed by: Phone: _ _ Date: _ _



pui-formCOVID-19 Confirmed Case Packet 5.5.20.pdf

Documents

Form and checklist for confirmed COVID-19 patients · COVID-19 Confirmed Case Investigation Worksheet . History of Activity 2 Days Before and 7 Days After Symptom Onset Instructions: