Philippine Integrated

Case Investigation Form

Disease Surveillance Coronavirus Disease (COVID-19)
and Response
Version 9
1) The Case Investigation Form (CIF) is meant to be administered as an interview by a health care worker or any personnel of the DRU. This is not a self-administered questionnaire.
2) Please be advised that DRUs are only allowed to obtain 1 copy of accomplished CIF from a patient.
3) Please fill out all blanks and put a check mark on the appropriate box. Never leave an item blank (write N/A). Items with * are required fields. All dates must be in MM/DD/YYYY format.
Disease Reporting Unit* DRU Region and Province PhilHealth No.*

Name of Interviewer Contact Number of Interviewer Date of Interview (MM/DD/YYYY)*

Name of Informant (if applicable) Relationship Contact Number of Informant

 Not applicable (New case)  Update case classification  Update disposition

If existing case  Not applicable (Unknown)  Update vaccination  Update exposure / travel history
(check all that apply)*  Update symptoms  Update lab result  Others, specify:
 Update health status / outcome  Update chest imaging findings _____________________________
Type of Client*  COVID-19 Case (Suspect, Probable, or Confirmed) ■
 Close Contact  For RT-PCR Testing (Not a Case of Close Contact)
Testing Category/Subgroup* (Check all that apply, refer to Appendix 2)  A  B  C  D 
■ E  F  G  H  I  J

Part 1. Patient Information

1.1. Patient Profile
Last Name* ORTIZ First Name (and Suffix)* JANINA BIANCA Middle Name* MENGUITO
Birthday (MM/DD/YYYY)* 12/20/1982 Age* 39 Sex*  Male ■ Female

Civil Status SINGLE Nationality* FILIPINO
Occupation PHYSICIAN Works in a closed setting?  Yes ■ No
  Unknown
1.2. Current Address in the Philippines and Contact Information* (Provide address of institution if patient lives in closed settings, see 1.5)
House No./Lot/Bldg.* Street/Purok/Sitio* Barangay* Municipality/City*
U920 CITYLAND PIONEER CONDO PIONEER ST. HIGHWAY HILLS MANDALUYONG
Province* Home Phone No. (& Area Code) Cellphone No.* Email Address
NCR 85846583 09178954852 [email protected]
1.3. Permanent Address and Contact Information (if different from current address)
House No./Lot/Bldg. Street/Purok/Sitio Barangay Municipality/City
same as above
Province Home Phone No. (& Area Code) Cellphone No. Email Address

1.4. Current Workplace Address and Contact Information

Lot/Bldg. Street Barangay Municipality/City
VETERANS MEMORIAL MEDICAL CENTER NORTH AVENUE DILIMAN QUEZON CITY
Province Name of Workplace Phone No./Cellphone No. Email Address
NCR
1.5. Special Population (indicate further details on exposure and travel history in Part 3)
Health Care Worker* 
■ Yes, name of health facility:________________________________
VETERANS MEMORIAL MEDICAL CENTER and location: QUEZON
_____________________
CITY  No
 Yes, country of origin: ___________________________ and Passport number: _______________________ 
■ No
Returning Overseas Filipino*
OFW:  OFW  Non-OFW
Foreign National Traveler*  Yes, country of origin: ___________________________ and Passport number: _________________________ 
■ No
Locally Stranded Individual /  Yes, City, Municipality, & Province of origin _________________________________ ■
 No
APOR / Local Traveler*  Locally Stranded Individual  Authorized Person Outside Residence / Local Traveler
 Yes, institution type: ___________________________ and name: ____________________________________  No
Lives in Closed Settings*
(e.g. prisons, residential facilities, retirement communities, care homes, camps, etc.)

Part 2. Case Investigation Details

2.1. Consultation Information
Have previous COVID-19 related consultation?  Yes, Date of First Consult (MM/DD/YYYY)* ___________________ 
■ No
Name of facility where first consult was done
2.2. Disposition at Time of Report* (Provide name of hospital/isolation/quarantine facility)
 Admitted in hospital ____________________________________________ Date and Time admitted in hospital ____________________________
 Admitted in isolation/quarantine facility ____________________________ Date and Time isolated/quarantined in facility ___________________

■ In home isolation/quarantine Date and Time isolated/quarantined at home ____________________
 Discharged to home If discharged: Date of Discharge (MM/DD/YYYY)* ______________  Others: ___________________________
2.3. Health Status at Consult* (Refer to Appendix 3) ■ Asymptomatic
  Mild  Moderate  Severe  Critical
2.4. Case Classification* (Refer to Appendix 1)  Suspect  Probable  Confirmed 
■ Non-COVID-19 Case
2.5. Vaccination information*
Date of vaccination* Name of Vaccine* Dose number (e.g. 1st, 2nd)* Vaccination center/facility Region of health facility Adverse event/s?
05/16/2021 PFIZER 1 QC LGU NCR  Yes 
■ No

06/06/2021 PFIZER 2 QC LGU NCR  Yes 

■ No

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 2.6. Clinical Information
Date of Onset of Illness (MM/DD/YYYY)* _________________________
Comorbidities (Check all that apply if present)
Signs and Symptoms (Check all that apply)

■ Asymptomatic  Dyspnea  None  Gastrointestinal
 Fever _______ °C  Anorexia ■
 Hypertension  Genito-urinary
 Cough  Nausea  Diabetes  Neurological Disease
 General weakness  Vomiting  Heart Disease  Cancer
 Fatigue  Diarrhea  Lung Disease  Others _______________
 Headache  Altered Mental Status Pregnant?  Yes, LMP (MM/DD/YYYY) ______________ 
■ No
 Myalgia  Anosmia (loss of smell, w/o any identified cause)
 Sore throat  Ageusia (loss of taste, w/o any identified cause) High-risk pregnancy?  Yes 
■ No
 Coryza  Others, specify____________ Was diagnosed to have Severe Acute Respiratory Illness?  Yes ■ No

Chest imaging findings suggestive of COVID-19
Date done Chest imaging done Results
 Chest radiography  Normal  Chest radiography: Hazy opacities, often rounded in morphology, with peripheral and lower lung dist.
 Chest CT  Pending  Chest CT: Multiple bilateral ground glass opacities, often rounded in morphology, w/ peripheral & lower lung dist.
 Lung ultrasound  Lung ultrasound: Thickened pleural lines, B lines, consolidative patterns with or without air bronchograms
■ None
  Other findings, specify ___________________________________________________
2.7. Laboratory Information
Have tested positive using ■ Yes, date of specimen Collection (MM/DD/YYYY)* ___________________
04/04/2021  No
RT-PCR before? * Laboratory* FE DEL MUNDO
___________________________________ No. of previous RT-PCR swabs done 5
____
Date collected* Date released Laboratory* Type of test* Results*
 RT-PCR (OPS)  Antigen; reason_________________  Pending  Negative
 RT-PCR (NPS) brand of kit ____________________  Positive  Equivocal
 RT-PCR (OPS and NPS)  Antibody Test  Others:
 Others: __________________________________________
 RT-PCR (OPS)  Antigen; reason_________________  Pending  Negative
 RT-PCR (NPS) brand of kit ____________________  Positive  Equivocal
 RT-PCR (OPS and NPS)  Antibody Test  Others:
 Others: __________________________________________
2.8. Outcome/Condition at Time of Report*
■ Active (currently admitted/isolation/quarantine)
  Recovered, date of recovery (MM/DD/YYYY)*______________  Died, date of death (MM/DD/YYYY)* _______________

If died, Immediate Cause: Antecedent Cause:

cause of death* Underlying Cause: Contributory Conditions:

PART 3. Contact Tracing: Exposure and Travel History

History of exposure to known probable and/or confirmed COVID-19 case 14 days before the onset 
■
Yes, date of last contact (MM/DD/YYYY)*______________
of signs and symptoms? OR If Asymptomatic, 14 days before swabbing or specimen collection? * No   Unknown
Has the patient been in a place with a known COVID-19 transmission 14 days before the onset of  Yes, International 
■ Yes, Local
signs and symptoms? OR If Asymptomatic, 14 days before swabbing or specimen collection? *  No  Unknown exposure
If International Travel, Inclusive travel dates: From: To:
country of origin With ongoing COVID-19 community transmission? ■ Yes
  No
Airline/Sea vessel Flight/Vessel Number Date of departure (MM/DD/YYYY) Date of arrival in PH (MM/DD/YYYY)

If Local Travel, specify travel places (Check all that apply, provide name of facility, address, and inclusive travel dates in MM/DD/YYYY)
Address Inclusive Travel Dates With ongoing COVID-19
Place Visited Name of Place
(Region, Province, Municipality/City) From: To: Community Transmission?
 Health Facility  Yes  No
 Closed Settings  Yes  No
 School  Yes  No
 Workplace  Yes  No
 Market  Yes  No
 Social Gathering  Yes  No
 Others  Yes  No
 Transport Service, specify the following:
Airline / Sea vessel / Bus line / Train Flight / Vessel / Bus No. Place of Origin Departure Date (MM/DD/YYYY) Destination Date of Arrival (MM/DD/YYYY)

Name (Use the back page if needed) Contact Number

- If symptomatic, provide names and contact numbers of persons who
were with the patient two days prior to onset of illness until this date
- If asymptomatic, provide names and contact numbers of persons who
were with the patient on the day specimen was submitted for testing
until this date

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Appendix 1. COVID-19 Case Definitions
SUSPECT PROBABLE
A) A person who meets the clinical AND epidemiological criteria A) A patient who meets the clinical criteria (on the left) AND is contact of a probable or confirmed case,
− Clinical criteria: or epidemiologically linked to a cluster of cases which had had at least one confirmed identified within
1) Acute onset of fever AND cough OR that cluster
2) Acute onset of ANY THREE OR MORE of the following signs or symptoms; B) A suspect case (on the left) with chest imaging showing findings suggestive of COVID-19 disease.
fever, cough, general weakness/fatigue, headache, myalgia, sore throat, Typical chest imaging findings include (Manna, 2020):
coryza, dyspnea, anorexia / nausea/ vomiting, diarrhea, altered mental − Chest radiography: hazy opacities, often rounded in morphology, with peripheral and lower lung
status. AND distribution
− Epidemiological criteria − Chest CT: multiple bilateral ground glass opacities, often rounded in morphology, with peripheral
1) Residing/working in an area with high risk of transmission of the virus (e.g and lower lung distribution
closed residential settings and humanitarian settings, such as camp and − Lung ultrasound: thickened pleural lines, B lines (multifocal, discrete, or confluent), consolidative
camp-like setting for displaced persons), any time w/in the 14 days prior to patterns with or without air bronchograms
symptoms onset OR C) A person with recent onset of anosmia (loss of smell), ageusia (loss of taste) in the absence of any
2) Residing in or travel to an area with community transmission anytime w/in other identified cause
the 14 days prior to symptoms onset; OR D) Death, not otherwise explained, in an adult with respiratory distress preceding death AND who was a
3) Working in health setting, including w/in the health facilities and w/in contact of a probable or confirmed case or epidemiologically linked to a cluster which has had at least
households, anytime w/in the 14 days prior to symptom onset; OR one confirmed case identified with that cluster
B) A patient with severe acute respiratory illness (SARI: acute respiratory infection CONFIRMED
with history of fever or measured fever of ≥ 38°C; cough with onset w/in the last A person with laboratory confirmation of COVID-19 infection,
10 days; and who requires hospitalization) irrespective of clinical signs and symptoms.
Appendix 2. Testing Category / Subgroup
A Individuals with severe/critical symptoms and relevant history of travel/contact G Residents, occupants or workers in a localized area with an active COVID-19 cluster, as identified
and declared by the local chief executive in accordance with existing DOH Guidelines and
Individuals with mild symptoms, relevant history of travel/contact, and considered vulnerable; consistent with the National Task Force Memorandum Circular No. 02 s.2020 or the Operational
B vulnerable populations include those elderly and with preexisting medical conditions that Guidelines on the Application of the Zoning Containment Strategy in the Localization of the
predispose them to severe presentation and complications of COVID-19 National Action Plan Against COVID-19 Response. The local chief executive shall conduct the
C Individuals with mild symptoms, and relevant history of travel and/or contact necessary testing in order to protect the broader community and critical economic activities and
Individuals with no symptoms but with relevant history of travel and/or contact or high risk of to avoid a declaration of a wider community quarantine.
D exposure. These include: H Frontliners in Tourist Zones:
D1 - Contact-traced individuals H1 All workers and employees in the hospitality and tourism sectors in El Nido, Boracay, Coron,
- Healthcare workers, who shall be prioritized for regular testing in order to ensure the stability Panglao, Siargao and other tourist zones, as identified and declared by the Department of
D2 Tourism. These workers and employees may be tested once every four (4) weeks.
of our healthcare system
D3 - Returning Overseas Filipino (ROF) workers, who shall immediately be tested at port of entry H2 All travelers, whether of domestic or foreign origin, may be tested at least once, at their own
- Filipino citizens in a specific locality within the Philippines who have expressed intention to expense, prior to entry into any designated tourist zone, as identified and declared by the
D4 return to their place of residence/home origin (Locally Stranded Individuals) may be tested Department of Tourism.
subject to the existing protocols of the IATF I All workers and employees of manufacturing companies and public service providers registered
in economic zones located in Special Concern Areas may be tested regularly.
E Frontliners indirectly involved in health care provision in the response against COVID-19 may be
J Economy Workers
tested as follows:
J1 Frontline and Economic Priority Workers, defined as those 1) who work in high priority sectors,
Those with high or direct exposure to COVID-19 regardless of location may be tested up to once both public and private, 2) have high interaction with and exposure to the public, and 3) who live
E1
a week. These include: (1) Personnel manning the Temporary Treatment and Quarantine or work in Special Concerns Areas, may be tested every three (3) months. These include but not
Facilities (LGU and Nationally-managed); (2) Personnel serving at the COVID-19 swabbing center; limited to:
(3) Contact tracing personnel; and (4) Any personnel conducting swabbing for COVID-19 testing - Transport and Logistics: drivers of taxis, ride hailing services, buses, public transport vehicle,
conductors, pilots, flight attendants, flight engineers, rail operators, mechanics, servicemen,
Those who do not have high or direct exposure to COVID-19 but who live or work in Special delivery staff, water transport workers (ferries, inter-island shipping, ports)
E2
Concern Areas may be tested up to every two to four weeks. These include the following: (1) - Food Retails: waiters, waitress, bar attendants, baristas, chefs, cooks, restaurant managers
Personnel manning Quarantine Control Points, including those from Armed Forces of the - Education: teachers at all levels of education and other school frontliners such as guidance
Philippines, Bureau of Fire Protection; (2) National / Regional / Local Risk Reduction and counselors, librarians, cashiers
Management Teams; (3) Officials from any local government / city / municipality health - Financial Services: bank tellers
office (CEDSU, CESU, etc.); (4) Barangay Health Emergency Response Teams and barangay - Non-Food Retails: cashiers, stock clerks, retail salespersons
officials providing barangay border control and performing COVID-19-related tasks; (5) Personnel - Services: hairdressers, barbers, manicurists, pedicurists, massage therapists, embalmers,
of Bureau of Corrections and Bureau of Jail Penology & Management; (6) Personnel manning the morticians, undertakers, funeral directors, parking lot attendants, security guards, messengers
One-Stop-Shop in the Management of ROFs; (7) Border control or patrol officers, such as - Construction: construction workers including carpenters, stonemasons, electricians, painters,
immigration officers and the Philippine Coast Guard; and (8) Social workers providing foremen, supervisors, civil engineers, structural engineers, construction managers, crane/tower
amelioration and relief assistance to communities and performing COVID-19-related tasks operators, elevator installers, repairmen
- Water Supply, Sewerage, Waster Management: plumbers, recycling/ reclamation workers,
Other vulnerable patients and those living in confined spaces. These include but are not limited garbage collectors, water/wastewater engineers, janitors, cleaners
F to: (1) Pregnant patients who shall be tested during the peripartum period; (2) Dialysis patients; - Public Sector: judges, courtroom clerks, staff and security, all national and local government
(3) Patients who are immunocompromised, such as those who have HIV/AIDS, inherited diseases employees rendering frontline services in special concern areas
that affect the immune system; (4) Patients undergoing chemotherapy or radiotherapy; (5) - Mass Media: field reporters, photographers, cameramen
Patients who will undergo elective surgical procedures with high risk for transmission; (6) Any All employees not covered above are not required to undergo testing but are encouraged to be
person who have had organ transplants, or have had bone marrow or stem cell transplant in the J2 tested every quarter. Private sector employers are highly encouraged to send their employees
past 6 months; (7) Any person who is about to be admitted in enclosed institutions such as for regular testing at the employers’ expense
jails, penitentiaries, and mental institutions. in order to avoid lockdowns that may do more damage to their companies.

Appendix 3. Severity of the Disease

MILD CRITICAL
Symptomatic patients presenting with fever, cough, fatigue, anorexia, myalgias; Patients manifesting with acute respiratory distress syndrome, sepsis and/or septic shock:
other non-specific symptoms such as sore throat, nasal congestion, headache, 1. Acute Respiratory Distress Syndrome (ARDS)
diarrhea, nausea and vomiting; loss of smell (anosmia) or loss of taste (ageusia) a. Patients with onset within 1 week of known clinical insult (pneumonia) or new or worsening respiratory
preceding the onset of respiratory symptoms with NO signs of pneumonia or symptoms, progressing infiltrates on chest X-ray or chest CT scan, with respiratory failure not fully
hypoxia explained by cardiac failure or fluid overload
MODERATE 2. Sepsis
1. Adolescent or adult with clinical signs of non-severe pneumonia (e.g. fever, a. Adults with life-threatening organ dysfunction caused by a dysregulated host response to suspected or
cough, dyspnea, respiratory rate (RR) = 21-30 breaths/minute, peripheral proven infection. Signs of organ dysfunction include altered mental status, difficult or fast breathing,
capillary oxygen saturation (SpO2) >92% on room air) low oxygen saturation, reduced urine output, fast heart rate, weak pulse, cold extremities or low blood
2. Child with clinical signs of non-severe pneumonia (cough or difficulty of pressure, skin mottling, or laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high
breathing and fast breathing [ < 2 months: > 60; 2-11 months: > 50; 1-5 years: > lactate or hyperbilirubinemia
40] and/or chest indrawing) b. Children with suspected or proven infection and > 2 age-based systemic inflammatory response
SEVERE syndrome criteria (abnormal temperature [> 38.5 °C or < 36 °C); tachycardia for age or bradycardia for
1. Adolescent or adult with clinical signs of severe pneumonia or severe acute age if < 1year; tachypnea for age or need for mechanical ventilation; abnormal white blood cell count
respiratory infection as follows: fever, cough, dyspnea, RR>30 breaths/minute, for age or > 10% bands), of which one must be abnormal temperature or white blood cell count.
severe respiratory distress or SpO2 < 92% on room air 3. Septic Shock
2. Child with clinical signs of pneumonia (cough or difficulty in breathing) plus at a. Adults with persistent hypotension despite volume resuscitation, requiring vasopressors to maintain
least one of the following: MAP > 65 mmHg and serum lactate level >2mmol/L
a. Central cyanosis or SpO2 < 90%; severe respiratory distress (e.g. fast b. Children with any hypotension (SBP < Sth centile or > 2 SD below normal for age) or two or three of the
breathing, grunting, very severe chest indrawing); general danger sign: following: altered mental status; bradycardia or tachycardia (HR < 90 bpm or > 160 bpm in infants and
inability to breastfeed or drink, lethargy or unconsciousness, or convulsions. heart rate < 70 bpm or > 150 bpm in children); prolonged capillary refill (> 2 sec) or weak pulse; fast
b. Fast breathing (in breaths/min): < 2 months: > 60; 2-11 months: > 50; 1-5 breathing; mottled or cool skin or petechial or purpuric rash; high lactate; reduced urine output;
years: > 40. hyperthermia or hypothermia.