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Covidreportform

This document is a COVID-19 case report form used to collect information about individuals who have tested positive for COVID-19. It requests identifying and contact information for the patient and reporter, details on COVID-19 testing, and clinical information such as symptoms, underlying conditions, hospitalization status, and outcomes. Completing this form helps public health officials monitor and respond to the spread of the virus.

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87 views1 page

Covidreportform

This document is a COVID-19 case report form used to collect information about individuals who have tested positive for COVID-19. It requests identifying and contact information for the patient and reporter, details on COVID-19 testing, and clinical information such as symptoms, underlying conditions, hospitalization status, and outcomes. Completing this form helps public health officials monitor and respond to the spread of the virus.

Uploaded by

api-460314063
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
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COVID-19 Case Report Form

Please complete this form for each laboratory confirmed COVID-19 patient. Fax form to 651-201-5743.
REPORTER INFORMATION

Today’s Date: ______/______/_______ Hospital/Clinic: _______________________________

Clinician Name: __________________________________ Phone: ______________________________________

Disease Reporter’s Name:__________________________ Phone: ______________________________________


COVID-19 TESTING INFORMATION

Lab Name: ______________________________________ Type of Specimen: ☐ NP ☐ OP


☐ Other:____________________
Specimen Collection Date: ______/______/_______

PATIENT INFORMATION

First Name: ______________________ Last Name: ____________________ Phone: _______________________

Address: ________________________________________________________ City: _________________________

Zip Code: ________________________ County: _______________________ State: ________________________

Date of Birth: ______/______/_______ Age: ____________ Years/Months Sex: ☐ Male ☐ Female

Does the patient work in a healthcare facility or congregate setting (e.g., long-term care facility, shelter, prison, jail)
☐ YES ☐ NO Facility Name:_____________________________________
Employee Occupation:______________________________
Did the patient work while ill? ☐ YES ☐ NO

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

Does the patient receive dialysis? ☐ YES ☐ NO

Does the patient work in a dialysis facility? ☐ YES ☐ NO


CLINICAL INFORMATION
Date of symptom onset: ______/______/_______ Does the patient have underlying conditions?
Is patient hospitalized? ☐ Y ☐ N ☐ None ☐ Immunocompromised
Admit Date: ________/________/___________ ☐ Unknown ☐ Pregnant
Hospital Name: ____________________________ ☐ Diabetes ☐ Chronic Lung Disease
☐ Y ☐ N ICU Admission? ☐ Hypertension ☐ Chronic Liver Disease
☐ Y ☐ N Intubated? ☐ Cardiac Disease ☐ Chronic Kidney Disease
☐ Y ☐ N Deceased? ☐ Other:______________________________
☐ Y ☐ N Chest X-ray or CT?
☐ Y ☐ N ECMO

v.4.23.2020

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