Hawaii MAVEN ID ________________
CDC nCoV ID ____________________

Interim 2019 Novel Coronavirus (2019-nCoV)
Patient Under Investigation (PUI) Form

Notify hospital infection preventionist and implement contact, droplet, and airborne precautions immediately. As soon as possible send completed
form to Hawaii Department of Health, Disease Outbreak Control Division by fax (808)586-4595 or secure/encrypted email at
doh.epi1@doh.hawaii.gov. Call to notify and confirm receipt of fax at (808)586-4586.

Today’s date__________

State_HI__ County______________________

NNDSS local record ID/Case ID1 _________________

Interviewer’s name________________________________

Phone_____________________

Email________________________

Physician’s name _________________________________

Phone_____________________

Pager or Email_________________

Sex ☐ M ☐ F Age________☐ yr ☐ mo

☐ US resident ☐ Non-US resident, country_______________________

Residency

PUI Criteria
Date of symptom onset_____________________
Does the patient have the following signs and symptoms (check all that apply)?
☐ Fever2 ☐ Cough ☐ Sore throat ☐ Shortness of breath
In the 14 days before symptom onset, did the patient:
Spend time in Wuhan City, China?
☐ Y ☐ N ☐ Unknown
Does the patient live in Wuhan City? ☐ Y ☐ N ☐ Unknown
Date traveled to Wuhan City______ Date traveled from Wuhan City______ Date arrived in US______
Have close contact3 with a person who is under investigation for 2019-nCoV while that person was ill?
☐ Y ☐ N ☐ Unknown
Have close contact3 with a laboratory-confirmed 2019-nCoV case while that case was ill?
☐ Y ☐ N ☐ Unknown
Additional Patient Information
Is the patient a health care worker? ☐ Y ☐ N ☐ Unknown
Have history of being in a healthcare facility (as a patient, worker, or visitor) in Wuhan City, China?
☐ Y ☐ N ☐ Unknown
Is patient a member of a cluster of patients with severe acute respiratory illness (e.g., fever and pneumonia requiring hospitalization) of
unknown etiology in which nCoV is being evaluated?
☐ Y ☐ N ☐ Unknown
Does the patient have these additional signs and symptoms (check all that apply)?
☐ Chills ☐ Headache ☐ Muscle aches ☐ Vomiting ☐ Abdominal pain ☐ Diarrhea ☐ Other, Specify_______________
Diagnosis (select all that apply): Pneumonia (clinical or radiologic) ☐ Y ☐ N Acute respiratory distress syndrome ☐ Y ☐ N
Comorbid conditions (check all that apply): ☐ None ☐ Unknown ☐ Pregnancy ☐ Diabetes ☐ Cardiac disease ☐ Hypertension
☐ Chronic pulmonary disease ☐ Chronic kidney disease ☐ Chronic liver disease ☐ Immunocompromised ☐ Other, specify
Is/was the patient: Hospitalized? ☐ Y, admit date_____________ ☐ N Admitted to ICU? ☐ Y ☐ N
Intubated? ☐ Y ☐ N On ECMO? ☐ Y ☐ N Patient died? ☐ Y ☐ N
Does the patient have another diagnosis/etiology for their respiratory illness? ☐ Y, Specify______________ ☐ N ☐ Unknown
Respiratory diagnostic results
Test
Influenza rapid Ag ☐ A ☐ B

Pos

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H. metapneumovirus
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Parainfluenza (1-4)
☐
Adenovirus
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Specimens for 2019-nCoV testing
Influenza PCR ☐ A ☐ B
RSV

Specimen type
NP swab
OP swab
Sputum
BAL fluid
Tracheal aspirate
1
2

3

Specimen ID

Neg

Pending

Not done

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Date collected

Sent to CDC?
☐
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Test
Rhinovirus/enterovirus
Coronavirus (OC43, 229E,
HKU1, NL63)
M. pneumoniae
C. pneumoniae
Other, Specify_________

Specimen type
Stool
Urine
Serum
Other, specify____
Other, specify____

Pos

Neg

Pending

Not done

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Specimen ID

Date collected

Sent to CDC?
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For NNDSS reporters, use GenV2 or NETSS patient identifier.
Fever may not be present in some patients, such as those who are very young, elderly, immunosuppressed, or taking certain medications. Clinical judgement should be used to
guide testing of patients in such situations
Close contact is defined as: a) being within approximately 6 feet (2 meters) or within the room or care area for a prolonged period of time (e.g., healthcare personnel, household
members) while not wearing recommended personal protective equipment (i.e., gowns, gloves, respirator, eye protection); or b) having direct contact with infectious secretions
(e.g., being coughed on) while not wearing recommended personal protective equipment. Data to inform the definition of close contact are limited. At this time, brief interactions,
such as walking by a person, are considered low risk and do not constitute close contact.

DIB: 1/22/ 2020