Maven ID: ___________________
Interview Date:___/___/___
Fact Sheet sent: ____/____/____

Letter for quarantine sent: ___/___/___

 Mail  Email

COVID19 Contact Interview Form
PATIENT INFORMATION
Last Name: ____________________________ First Name: ____________________________ MI:_________
Date of Birth: ____/____/____
Gender:  Male  Female
Name of Proxy:______________________________________
Home Phone: __________________

Cell Phone: __________________ Email: ______________________

Resident of Hawaii:  Yes  No
(If no, collect both address within Hawaii and permanent address)
Street Address: ________________________________________________
City: __________________________ County: _________________________ Zip: ____________
Permanent Address: Street Address: ________________________________________________
City: __________________________ State: ______________ Zip: ____________ Country: _________________
Race:
 Asian: ______________  Native American /Alaskan Native  Black or African American
 Native Hawaiian/Pacific Islander: ___________  White  Unk  Other: ____________
Ethnicity:
 Hispanic/Latino  Non-Hispanic/Non-Latino
 Unk
Occupation: _____________________________________________________________________
Work/School Name and Address: _______________________________________________________________
EXPOSURE HISTORY
Did you travel outside of the US, to another state, or within Hawaii at any time during the last 4 weeks?
 Yes  No  Unk
(If Yes, please specify all locations and dates below)
Location: address, city, county, state, country
Departure date
Return Date
(Home address and travel history if tourist)
(Arrival date if tourist) (Departure date if tourist)

Contact with a laboratory confirmed COVID19 case:
Household contact

Healthcare contact

Community Contact

Has anyone else informed you about the exposure?  Yes  No
If yes, Name(s)____________________________________
Place of Exposure: _________________________ Date of last exposure: ___/____/___
Exposure Details/Notes:______________________________________________________________
_________________________________________________________________________________
DIB 03/2020

COVID19, Page 1 of 2

 SIGNS AND SYMPTOMS
Are/Were you symptomatic?
 Yes  No  Unk
If yes, Date of Illness Onset: ____/____/____
First Symptom? _______________________________
General Symptoms (Ask about each General Symptom individually)
Fever (>100.4F)
 Yes  No  Subjective
If Yes, fever onset date: ____/____/____ Max temp (°F): _______ Duration of fever (days): ______
Cough
 Yes  No  Unk
Myalgia (Body / Muscle aches)
 Yes  No  Unk
Headache
 Yes  No  Unk
Chills
 Yes  No  Unk
Sore Throat
 Yes  No  Unk
Shortness of Breath
 Yes  No  Unk
Nausea or Vomiting
 Yes  No  Unk
Runny nose
 Yes  No  Unk
Nasal Congestion
 Yes  No  Unk
Loss of Smell
 Yes  No  Unk
Loss of Taste
 Yes  No  Unk
Other Symptoms (fatigue, rash, etc.)
 Yes  No  Unk
If yes, please describe: __________________________________________________________________
Were you tested for COVID-19?  Yes  No
What date did you visit the doctor/clinic? ___________________________
Which clinic?_________________________________________________
Specimen Collection Date:_______________________________________
Test result:

Positive

Negative

Unknown

FOLLOW-UP
Daily Monitoring via:

 Automated Text Message_HealthSpace
 Phone Call

Individual was informed of COVID-19 risk?

 Yes 

No

Quarantine period: from____/____/____ to ____/____/____

DIB 03/2020

COVID19, Page 2 of 2

 Symptom Log for Persons Being Active Monitored for COVID-19
Name: _________________________________________

Gender: M / F

Address: _______________________________________

Phone Number: _________________________________

Surveillance Start Date: ____________

Source: ________________________________________

Source Relationship: _____________________________

Isolation/Quarantine Release Date: __________

Type of Contact:

Text (T)

Day Number

Home Visit (HV)
1

(after last contact)

Phone Call (PC)

2

3

4

DOB: _______________

Voicemail (VM)

5

6

Maven ID: ___________________

Unable to Contact (UAC)

7

8

9

10

11

12

13

14

Date
Type of
Contact
No
Symptoms

Y
Fever
Temp (max)
On anti-fever
meds
Date of last
use
Cough
Shortness of
breath
Sore throat
Muscle aches
Abdominal
pain
Vomiting
Nausea
Diarrhea
Other
(specify)

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

 Symptom Log for Persons Being Monitored for Novel Coronavirus
Name: _________________________________________

DOB: _____________

Type of Contact:

Phone Call (PC)

Text (T)

17

19

Day Number

Home Visit (HV)

15

(after last contact)

16

18

Maven ID: ___________________

Voicemail (VM)

20

Isolation/Quarantine Release Date: __________

Unable to Contact (UAC)

21

22

23

24

25

26

27

Date
Type of
Contact
No
Symptoms

Y
Fever
Temp (max)
On anti-fever
meds
Date of last
use
Cough
Shortness of
breath
Sore throat
Muscle aches
Abdominal
pain
Vomiting
Nausea
Diarrhea
Other
(specify)

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N