COVID-19 Assessment Information:
Evaluating Persons with Fever and Acute Respiratory Illness (updated 2/28/2020)



Obtain a detailed travel history on ALL patients being evaluated for fever and acute respiratory illness.
Use the assessment criteria below to determine if COVID-19 should be included in the differential diagnosis.

Name:
Address:
Assessment Criteria
A) Did/Does the patient have a fever?

DOB:
Yes

(Fever may not be present in some patients, use clinical
judgement to guide testing.)
B) Does the patient have symptoms of lower

respiratory illness (LRI) (e.g. cough or shortness of
breath)?
C) Does the patient require hospitalization for
severe LRI (e.g., pneumonia, ARDS)?
D) Has the patient tested negative for other
common respiratory pathogens? (e.g., influenza)?
E) In the 14 days before symptom onset, did the
patient:
i. Have close contact with a lab-confirmed
COVID-19 patient?

No

Interview date:
Phone:
Comments
Fever onset date: ____/____/_____
Highest measured temperature: _________ □ °F □ °C
□ Check if SUBJECTIVE fever only
Symptom onset date: ____/____/____
□ Cough □ Sore throat □ Difficulty breathing
Other Symptoms (list):_________________________

Dates of contact with COVID-19 lab-confirmed case:
____/____/_____to____/____/____

Name of COVID-19 lab-confirmed case (if known):
____________________________________________
Nature of contact: □ Family/Household □ Coworker
□ Healthcare worker □ Travel □ Other: ____________
Comments:___________________________________

ii. Travel from affected geographic areas*?
CDC Coronavirus Travel Information:
https://www.cdc.gov/coronavirus/2019ncov/travelers/index.html

Dates: ____/____/_____ to ____/____/______
Arrival in US: ____/____/______
Locations visited in 14 days before symptom onset:

Suspect COVID-19 if you answered YES to
•
•
•

A or B and Ei, OR
A and B and C and Eii, OR
A and B and C and D

*If patient does not meet case definition but there
is a high index of clinical suspicion, contact LHJ.

IMMEDIATELY:
 Ensure that the patient is masked and isolated in a private room with the door closed AND
 Ensure that healthcare personnel entering the room use standard, contact, AND airborne precautions, INCLUDING eye
protection (e.g., goggles or face shield that covers the front and sides of the face).
 Note: Airborne precautions includes use of fit-tested NIOSH-certified N95 filtering facepiece respirator or higher.
 Notify your healthcare facility’s infection control personnel.
 Perform any clinically indicated respiratory and other diagnostic tests and note results below:
□
□
□
□
□
□

Rapid Influenza: □ A □ B
Rapid Strep
Viral Respiratory Panel
Pneumonia
Legionella
Other: _______________

□ Neg □ Pos □ Pending □ Not Done
□ Neg □ Pos □ Pending □ Not Done
□ Neg □ Pos □ Pending □ Not Done
□ Neg □ Pos □ Pending □ Not Done
□ Neg □ Pos □ Pending □ Not Done
□ Neg □ Pos □ Pending □ Not Done

Other clinically relevant testing:
Chest X-Ray □ Not Done □ Pending □ Normal
□ Abnormal: _________________________
Other: ________________________________
Other: ________________________________

 Call your local health jurisdiction (LHJ) with the above information to discuss the case and determine whether to test for
SARS-CoV-2. (If after hours and the LHJ is not available, call the Washington State Department of Health at 206-418-5500.)

 If instructed by your local health department, collect samples for SARS-CoV-2 testing. See 2019-nCoV tab here:
https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/PublicHealthLaboratories/MicrobiologyLabTestMenu
□ Nasopharyngeal (NP) swab* and □ Oropharyngeal (OP) swab*
□ If readily available or if patient is intubated, lower respiratory specimen
*synthetic swab in 2-3 ml viral transport media

1/1