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

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
Symptoms, clinical course, past medical history and social history
Collected from (check all that apply): Patient interview Medical record review
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/intellectual Yes No Unknown (If YES, specify)
disability
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 Specimen Specimen Date State Lab State Lab Sent to CDC Lab
done Type ID Collected Tested Result CDC 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:_________

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). 2