Scribd
Upload
88 views

COVID-19 Patient Reporting Form: Reporter Information

This COVID-19 patient reporting form requests information to report cases of COVID-19. It asks for reporter and patient identifying information, symptoms, exposure and travel history, clinical information including hospitalization details, underlying conditions, testing results, and definitions of close contact. Completing the form allows reporting of patients requiring COVID-19 testing or those laboratory confirmed to have COVID-19.

Uploaded by

Shinta Devianti
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
88 views

COVID-19 Patient Reporting Form: Reporter Information

This COVID-19 patient reporting form requests information to report cases of COVID-19. It asks for reporter and patient identifying information, symptoms, exposure and travel history, clinical information including hospitalization details, underlying conditions, testing results, and definitions of close contact. Completing the form allows reporting of patients requiring COVID-19 testing or those laboratory confirmed to have COVID-19.

Uploaded by

Shinta Devianti
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

COVID-19 Patient Reporting Form

Please complete this form for each patient that COVID-19 testing is requested for. Fax form to 651-201-5743 and then
include this form with specimen submission. If you have a patient who is laboratory confirmed for COVID-19, report
case using this form.
REPORTER INFORMATION

Today’s Date: ____________________________________ Hospital/Clinic: _______________________________

Clinician Name: __________________________________ Phone: ______________________________________

PATIENT INFORMATION

First Name: ______________________ Last Name: ____________________ Sex: Male/Female

Address: ________________________ City: _________________________ County: _____________________

Phone: __________________________ Date of Birth: __________________ Age: ________ Years/Months

Additional information required prioritization of testing


Does the patient live in a congregate setting (e.g., long-term care, shelter, group home) ☐ YES ☐ NO
Facility Name:_____________________________________

Is the patient a healthcare worker who provides direct patient care? ☐ YES ☐ NO
Employment Location:_____________________________________
Did the patient work while ill? ☐ YES ☐ NO

SYMPTOMS
Date of symptom onset: ______/______/_______

☐ Fever ☐ Chills ☐ Abdominal Pain ☐ Pneumonia


☐ Cough ☐ Headache ☐ Diarrhea ☐ ARDS
☐ Shortness of breath ☐ Sore Throat ☐ Vomiting ☐ Muscle aches

EXPOSURE HISTORY
In the 14 days before symptom onset, did the patient:
☐ YES ☐ NO Travel? Location:______________________________________________
Dates: ________________________________________________

☐ YES ☐ NO Have close contact1 with a lab confirmed 2019-nCoV case while that case was ill?
If yes, Case Name: ______________________________________________
CLINICAL INFORMATION
☐ Y ☐ N Hospitalized? Admit Date: ___________ Does the patient have underlying conditions?
Hospital Name: ______________________________ ☐ None ☐ Immunocompromised
☐ Y ☐ N ICU Admission? ☐ Unknown ☐ Pregnant
☐ Y ☐ N Intubated? ☐ Diabetes ☐ Chronic Lung Disease
☐ Y ☐ N Deceased? ☐ Hypertension ☐ Chronic Liver Disease
☐ Y ☐ N Chest X-ray or CT? ☐ Cardiac Disease ☐ Chronic Kidney Disease
☐ Y ☐ N ECMO ☐ Other:________________________________

v.3.16.2020
LABORATORY TESTING
☐ YES ☐ NO Has the patient been tested for influenza?
Result: ☐ Positive ☐ Negative
Test Type: ☐ Rapid Test ☐ PCR
☐ YES ☐ NO Has the patient been tested for any other viral respiratory illness?
Result: _________________________________________________

COVID 2019 TESTING


Date
Specimen Type Positive Negative Equivocal Not Done
Collected
NP swab
OP swab
Sputum
Other:

1
CDC defines “close contact” as: 1) being within approximately 6 feet or within the room or care area for a prolonged period of time while not wearing
recommended PPE (i.e., gowns, gloves, respirator, eye protection); OR 2) having direct contact with infectious secretions (e.g., being coughed on) while not wearing
recommended PPE. At this time, brief interactions, such as walking by a person, are considered low risk and do not constitute close contact

You might also like