Revised Case Report Form For Confirmed Novel Coronavirus COVID-19 (Report To WHO Within 48 Hours of Case Identification)
Revised Case Report Form For Confirmed Novel Coronavirus COVID-19 (Report To WHO Within 48 Hours of Case Identification)
Revised Case Report Form For Confirmed Novel Coronavirus COVID-19 (Report To WHO Within 48 Hours of Case Identification)
Age (years): [___][___][___] if <1 year old, [___][___] in months or if < 1 month, [___][___] in days
Any symptoms* or signs at time of specimen collection that resulted in first laboratory confirmation?
□ No (i.e., asymptomatic) □ Yes □ Unknown
If yes, date of onset of symptoms: [_D_][_D_]/[_M_][_M_]/[_Y_][_Y_][_Y_][_Y_]
If yes
Did the case receive care in an intensive care unit (ICU)? □ No □ Yes □ Unknown
Did the case receive ventilation? □ No □ Yes □ Unknown
Did the case receive extracorporeal membrane oxygenation? □ No □ Yes □ Unknown
Section 3: Exposure risk in the 14 days prior to symptom onset (prior to testing if asymptomatic)
Is case a Health Care Worker (any job in a health care setting): □ No □ Yes □ Unknown
Has the case travelled in the 14 days prior to symptom onset? □ No □ Yes □ Unknown
If yes, please specify the places the patient travelled to and date of departure from the places:
Country City Date of Departure from the place
1. Country ________________________________City ________________________________ Date ________________________________
2. Country ________________________________City ________________________________ Date ________________________________
3. Country ________________________________City ________________________________ Date ________________________________
Has case visited any health care facility in the 14 days prior to symptom onset? □ No □ Yes □ Unknown
Has case had contact with a confirmed case in the 14 days prior to symptom onset? □ No □ Yes □ Unknown
If yes, please list unique case identifiers of all probable or confirmed cases:
If yes, please explain contact setting: _____________________________________________________________________________________
____________________________________________________________________________________________________________________________
Contact ID First Date of Contact Last Date of Contact
1. ________________________________ Date ________________________________ Date ________________________________
2. ________________________________ Date ________________________________ Date ________________________________
3 ________________________________ Date ________________________________ Date ________________________________
4 ________________________________ Date ________________________________ Date ________________________________
5 ________________________________ Date ________________________________ Date ________________________________
2
Section 4: Outcome : complete and re-sent the full form as soon as outcome of disease is known or after
30 days after initial report
If case was asymptomatic at time of specimen collection resulting in first laboratory confirmation, did the case develop any
symptoms or signs at any time prior to discharge or death:
□ Yes, asymptomatic case (as previously reported ) developed symptoms and/or signs of illness
□ Unknown
Clinical Course:
Admission to hospital (may have been previously reported): □ No □ Yes □ Unknown
If admitted to hospital:
First date of admission to hospital: [_D_][_D_]/[_M_][_M_]/[_Y_][_Y_][_Y_][_Y_]
Did the case receive care in an intensive care unit (ICU)? □ No □ Yes □ Unknown
Did the case receive ventilation? □ No □ Yes □ Unknown
Did the case receive extracorporeal membrane oxygenation? □ No □ Yes □ Unknown