Public Health Apps

COVID-19 PUI and Case Report

Coronavirus Disease (COVID-19) is a disease caused by the newly emerged coronavirus SARS-CoV-2. To prevent further spread of the virus and to better understand its impact on health outcomes, CDC has developed a form that provides a standardized approach to reporting COVID-19 cases (individuals with at least one respiratory specimen that tested positive for the virus that causes COVID-19). Collect data on demographic, clinical, and epidemiologic characteristics, exposure and contact history, course of illness and care received and more. This information is needed to track the impact of the outbreak and inform public health response.

Source: https://www.cdc.gov/coronavirus/2019-ncov/php/reporting-pui.html

COVID-19 PUI and Case Report iPhone, iPad COVID-19 PUI and Case Report Android COVID-19 PUI and Case Report Web, Desktop
COVID-19 PUI and Case Report

Patient Identifier (NOT TRANSMITTED TO CDC)

First Name

Last Name

Date of birth (MM/DD/YYYY)

Human Infection with 2019 Novel Coronavirus Person Under Investigation (PUI) and Case Report Form

Identification Information

Reporting jurisdiction

Reporting health department

Contact ID

Case state/local ID

CDC 2019-nCoV ID

NNDSS loc. rec. ID/Case ID

Interviewer information

Last name of interviewer

First name of interviewer

Affiliation / Organization

Telephone

Email

Basic information

What is the current status of this person?

Report date of PUI to CDC (MM/DD/YYYY)

Report date of Case to CDC (MM/DD/YYYY)

County of residence

State of residence

Ethnicity

Sex

Race (check all that apply)

Asian

American Indian/ Alaska Native

Black

Native Hawaiian/ Other Pacific Islander

White

Unknown

Other

Other specified race

Date of birth (MM/DD/YYYY)

Age

Age units

Date of first positive specimen collection (MM/DD/YYYY)

Date unknown

Date not applicable

Symptoms

Did the patient develop pneumonia?

Did the patient have acute respiratory distress syndrome?

Did the patient have another diagnosis/etiology for their illness?

Did the patient have an abnormal chest X-ray?

Symptoms present during course of illness

If symptomatic, onset date (MM/DD/YYYY)

If symptomatic, onset date - unknown

If symptomatic, date of symptom resolution (MM/DD/YYYY)

If symptomatic, state of resolution

Hospitalization

Was the patient hospitalized?

Admission date 1 (MM/DD/YYYY)

Discharge date 1 (MM/DD/YYYY)

Was the patient admitted to an intensive care unit (ICU)?

Did the patient receive mechanical ventilation (MV)/intubation?

Total days with MV

Did the patient receive extracorporeal membrane oxygenation (ECMO)?

Did the patient die as a result of this illness?

Date of Death (MM/DD/YYYY)

Date of Death Unknown

Health Care Information

Is the patient a health care worker in the United States?

Does the patient have a history of being in a healthcare facility (as a patient, worker or visitor) in China?

In the 14 days prior to illness onset, did the patient have any of the following exposures:

Travel to Wuhan

Travel to Hubei

Travel to mainland China

Travel to other non-US country

Other Country

Household contact with another lab-confirmed COVID-19 case-patient

Community contact with another lab-confirmed COVID-19 case-patient

Any healthcare contact with another lab-confirmed COVID-19 case-patient

Healthcare contact with another lab-confirmed COVID-19 case-patient -- patient

Healthcare contact with another lab-confirmed COVID-19 case-patient -- visitor

Healthcare contact with another lab-confirmed COVID-19 case-patient -- healthcare worker

Animal exposure

Exposure to a cluster of patients with severe acute lower respiratory distress of unknown etiology

Other exposure

Other Exposure Specifics

Unknown exposure

If the patient had contact with another COVID-19 case, was this person a U.S. case?

If yes, specify nCoV ID of source case

Under what process was the PUI or case first identified? (check all that apply)

Process Clinical evaluation leading to PUI determination

Process Contact tracing of case patient

Process Routine surveillance

Process EpiX notification of travelers

DGMQID

Process Unknown

Process Other

Other Process Specifics

Symptoms, clinical course, past medical history and social history

Collected from patient interview

Collected from medical record review

During this illness, did the patient experience any of the following symptoms?

Fever >100.4F (38C)

Subjective fever (felt feverish)

Chills

Muscle aches (myalgia)

Runny nose (rhinorrhea)

Sore throat

Cough (new onset or worsening of chronic cough)

Shortness of breath (dyspnea)

Nausea or Vomiting

Headache

Abdominal pain

Diarrhea (≥3 loose/looser than normal stools/24hr period)

Other symptoms

Other symptoms specifics

Pre-existing medical conditions

Pre-existing medical conditions?

Chronic lung disease (asthma/emphysema/COPD)

Diabetes Mellitus

Cardiovascular disease

Chronic renal disease

Liver disease

Immunocompromised condition

Neurologic/neurodevelopmental/intellectual disability

Neurologic/neurodevelopmental/intellectual disability specifics

Other chronic diseases

Other chronic disease specifics

If female, currently pregnant

Current smoker

Former smoker

Respiratory Diagnostic Testing

Influenza A Rapid Ag

Influenza B Rapid Ag

Influenza A PCR

Influenza B PCR

RSV

H. metapneumovirus

Parainfluenza (1-4)

Adenovirus

Rhinovirus/enterovirus

Coronavirus (OC43, 229E, HKU1, NL63)

M. pneumoniae

C. pneumoniae

Other positive pathogens

Other positive pathogens specifics

Specimens for COVID-19 Testing

Nasopharyngeal (NP) Swab

Specimen ID

Collection date (MM/DD/YYYY)

State Lab Tested

State Result

Sent to CDC

CDC Result

Oropharyngeal (OP) Swab

Specimen ID

Collection date (MM/DD/YYYY)

State Lab Tested

State Result

Sent to CDC

CDC Result

Sputum

Specimen ID

Collection date (MM/DD/YYYY)

State Lab Tested

State Result

Sent to CDC

CDC Result

Other Specimen

Other Specimen Details

Other Specimen Specifics

Specimen ID

Collection date (MM/DD/YYYY)

State Lab Tested

State Result

Sent to CDC

CDC Result