COVID-19 Investigator: Phone number: CASE Last name: First and middle name: Date of Birth: / Gender: Maiden name: / Estimated? Female Male Age: Other Suffix: Alias: Does patient speak English: Address line: Zip: City: State: Yes ( Long-term care resident: Corrections facility Homeless )- - Ethnicity: Type: Yes No Unknown Yes No Unknown Yes No Unknown Facility name: If no, what language? ___________________ American Indian or Alaskan Native Black or African American Hawaiian or Pacific Islander Race: County: Phone: No Hispanic or Latino Unknown White Asian Not Hispanic or Latino Unknown Parent/Guardian name: Parent/Guardian Phone: Is patient aware of diagnosis: ( )- - Yes Type: No Unknown EVENT Event outcome: Outbreak related: Onset / / date: Survived this illness Died from this illness Died unrelated to this illness Unknown / / Yes No Unknown Outbreak name: Exposure setting: Epi-linked: Location acquired: Yes No Unk To whom:______________ In USA, in reporting state In USA, outside reporting state Outside USA Unknown State: Last name: Healthcare provider information Diagnosis date: First name: ARNP DO Provider title: MD NP PA Facility name: Address line 1: Address line 2: Country: Zip code: City: State: County: Phone : ( )- - Type: LABORATORY FINDINGS Laboratory: Date received: Result type: Organism: / / Preliminary Final Result type: Organism: Result date: / / Test type: / / Result: Positive Negative COVID-19 Laboratory: Date received: Collection date: Accession #: Specimen source: / / Preliminary COVID-19 Collection date: Accession #: Specimen source: Final Result date: / / Test type: / / Result: Positive Negative PATIENT NAME __________________________ CONFIDENTIAL Iowa Department of Public Health OCCUPATIONS Interpret ‘occupation’ very loosely and consider every person to have at least one ‘occupation’. Occupation type: Worked after symptom onset: Job title: Yes Date worked from: / / Address: Date worked to: Removed from duties: / / Zip code: Yes Date removed: / No Unknown No Facility name: Unknown City: / Handle food: Attend or provide child care: Attend or teach school: Work in a lab setting: Phone: Yes Yes Yes Yes No No No No State: ( Unknown Unknown Unknown Unknown )- - Type: Work in a health care setting: Direct patient care duties in lab or health care setting: Health care worker type: Occupation type: Worked after symptom onset: Yes Date worked from: / / Address: Date worked to: Removed from duties: / / Zip code: Yes Date removed: / County: Yes No Unknown Yes No Unknown Job title: No Unknown No Facility name: Unknown City: / Handle food: Attend or provide child care: Attend or teach school: Work in a lab setting: Phone: Yes Yes Yes Yes No No No No Unknown Unknown Unknown Unknown State: ( )Type: Work in a health care setting: Direct patient care duties in lab or health care setting: Duties performed in health care setting: County: Yes No Unknown Yes No Unknown HOSPITALIZATIONS Was the case hospitalized overnight for this illness? Yes No Unknown / Hospital: / Admission date: Was the patient admitted to an intensive care unit (ICU)? Days hospitalized: Did the patient receive mechanical ventilation / intubation? Yes No Unk Yes No Unk Discharge date: Did the patient receive ECMO? / Yes / No Unk Symptoms CLINICAL INFO & DIAGNOSIS Fever (100.4F) Yes No Unk Shortness of breath Yes No Unk Subjective fever Yes No Unk Highest known ________ Abdominal pain Yes No Unk Chills Yes No Unk Vomiting Yes No Unk Muscle Aches Yes No Unk Nausea Yes No Unk Headache Yes No Unk Diarrhea Yes No Unk Runny nose Yes No Unk Other: Sore throat Yes No Unk Cough Yes No Unk Date returned to normal activities: / / _____________________________ _____________________________ _____________________________ Symptoms ongoing at time of interview Yes No Complications: Pneumonia Yes No Unk Acute Respiratory distress syndrome Yes No Unk Abnormal chest X-ray Yes No Unk Another diagnosis/etiology for respiratory illness Yes No Unk Center for Acute Disease Epidemiology Fax: 515-281-5698 If yes, specify ____________________________ Revised Mar-20 2 PATIENT NAME __________________________ CONFIDENTIAL Pre-existing medical conditions Does the patient have any diagnosed pre-existing medical conditions? Chronic Lung Disease (asthma/emphysema/COPD) Yes No Unk Yes No Iowa Department of Public Health Unknown Diabetes Mellitus Yes No Unk Cardiovascular disease Yes No Unk Chronic Renal disease Yes No Unk Chronic liver disease Yes No Unk Immunocompromised condition Yes No Unk Neurologic/neurodevelopmental/ intellectual disability Yes No Unk If yes, specify ________________________________ If yes, specify ________________________________ Other chronic diseases Yes No Unk If female, currently pregnant Yes No Unk Current Smoker Yes No Unk Former Smoker Yes No Unk Health care provider visited: Yes No Unknown Please enquire about all healthcare visits after symptom onset. (i.e. urgent care, primary care, hospital emergency department) If Yes, complete the following table: Transportation: Facility (private vehicle, name: ambulance, etc) Address: Zip code: City: Phone: Provider name: ( )- - State: County: Type: Date visited: / Time visited: / / Time visited: Title: Transportation: Facility name: (private vehicle, ambulance, etc) Address: Zip code: City: Phone: Provider name: / ( )- - State: County: Type: Date visited: Title: RISK FACTORS/TRAVEL Risk Factors/Travel Information – In the 14 days prior to onset of symptoms did the case: Travel outside U.S? Yes No Unk Country: Departure date: Travel Country: Travel within U.S.? Yes No Unk Travel within Iowa? Yes No Unk State: Departure date: City: Departure date: City in Iowa: City in Iowa: City in Iowa: / / Return date: / / / / Return date: / / / / Return date: / / Departure date: / / Return date: / / Departure date: / / Return date: / / Departure date: / / Return date: / / Risk Factors/Travel Information – In the 14 days prior to onset of symptoms did the case: Did the case have contact with another laboratory-confirmed COVID-19 patient? Yes No If yes, please specify: Household contact Unknown In the community Other, please specify: In a healthcare setting as a patient In a healthcare setting as a visitor In a healthcare setting as a healthcare worker_________________ Center for Acute Disease Epidemiology Fax: 515-281-5698 Revised Mar-20 Unknown 3 CONFIDENTIAL PATIENT NAME __________________________ If the patient had contact with another COVID-19 case, was the person a U.S. case? Iowa Department of Public Health Yes No Name of case _______________________________________ Case ID _____________________ Phone number ____________________________ Did the case have exposure to a cluster of patients with severe acute lower respiratory distress of unknown etiology? If yes, please specify: Cruise School/university Daycare Transit Hotel Work Household Other, please specify: Rideshare_________________ Did the case have any contact with any types of animals including livestock, pets, or wildlife, whether at home or away? Location: Type of animal: When: Yes No Setting: CONTACTS Number of people living in case’s household: Please list household contacts and provide education to self-isolate until 14 days from last exposure to a known case. Ill people should maintain a six foot distance from other people and animals in the household. Name Type of contact / last contact date Phone number CONTACTS Are there close contacts of the case with same symptoms: Yes No Unknown Close contacts of the case with the same symptoms. All symptomatic household contacts should be interviewed and recorded in IDSS. Name DOB Gender Address/Phone / / Male Female Zip code: Relationship to case Spouse Child Sibling Roommate Parent/ guardian List symptoms Sexual contact Family member (non-household) Friend/acquaintance Contact- work/school/etc Unknown/Other Symptom onset date / Is contact a case? Yes No Restaurant Gatherings Food Animal Water / If this contact is a case create a new event and/or case for this contact. DOB Gender Address/Phone Name / / Male Female Zip code: Relationship to case Spouse Child Sibling Roommate Parent/ guardian Phone: Same exposures List symptoms Sexual contact Family member (non-household) Friend/acquaintance Contact- work/school/etc Unknown/Other Symptom onset date / / Phone: Same exposures Restaurant Gatherings Food Animal Water Is contact a case? Yes No If this contact is a case create a new event and/or case for this contact. Center for Acute Disease Epidemiology Fax: 515-281-5698 Revised Mar-20 4 CONFIDENTIAL PATIENT NAME __________________________ Name DOB / Iowa Department of Public Health Gender / Address/Phone Male Female Zip code: Relationship to case Spouse Child Sibling Roommate Parent/ guardian List symptoms Sexual contact Family member (non-household) Friend/acquaintance Contact- work/school/etc Unknown/Other Symptom onset date / / Phone: Same exposures Restaurant Gatherings Food Animal Water Is contact a case? Yes No If this contact is a case create a new event and/or case for this contact. NOTES: Center for Acute Disease Epidemiology Fax: 515-281-5698 Revised Mar-20 5