Page of v.05/18/2020 Provider Signature Date
Form and checklist for confirmed COVID-19 patients Sec PRV
Prim PRV
Name of investigator: Date test result received:
Name of patient: DOB:_____________ Gender: _______
CDC ID number: NBS number:
Minors: Guardian Name: Guardian Job Status: Employed Unemployed Retired
Address:
Phone number(s): Email:
Date and approximate time of symptom onset: Infectious period start date: (Onset – 2 days)
Initial symptoms:
Contact with a known case of COVID-19: Yes □ No □ Name:
Recent travel history? Yes □ No □ Location and date(s):
Recent contact with any visitors from another location? Yes □ No □ Location and date(s):
Patient reside in a congregate or LTCF? Yes □ No □ Name, address:
Does the patient have a thermometer? Yes □ No □ Does the patient have a mask? Yes □ No □
Last date of patient’s isolation (a.k.a. infectious period end date): Persons with COVID-19 who have symptoms and were directed to care for themselves at home may discontinue home isolation under the following conditions:
At least3 days (72 hours)have passed since recovery defined as resolution of fever without the useof fever- reducing medications and improvement in respiratory symptoms (e.g., cough, shortness ofbreath); AND
At least 10 days have passed since symptoms first appeared.
The following steps for each patient should be complete. Check-off when completed.
□ Verify that hcp notified patient of test result□ Request medical records and patient demographic information from health care facility as needed□ Advise healthcare facilities where patient was seen to review infection control surrounding visit□ If applicable, patient advised on home isolation□ Interview patient□ If applicable, complete source investigation□ Contacts interviewed and emailed information□ Complete CDC PUI and Case Report Form as much as possible (prioritize variables on the first page) and
return to Epi. For instructions for completing the case report form visit: https://www.cdc.gov/coronavirus/2019-ncov/downloads/COVID-19-Persons-Under-Investigation-and-Case-Report-Form-Instructions.pdf
□ When available, send EPI contact line list with names, DOBs, and risk level□ Contact line list returned to Epi indicating that contacts have cleared from quarantine□ Patient provided with release from isolation letter, and last date of patient’s isolation forwarded to Epi
CL 45 TP Code 01 02 07 30 TP Code EPSDT 547 EPI Investigation 04 Group Services 19
AT TT Medicaid # (V01.79)
Health Center HR#
POV Counsel POS COVID-19
Other POV
tssteenhoutOval
tssteenhoutSticky NoteAccepted set by tssteenhout
Human Infection with Coronavirus Disease 2019 (COVID-19) Surveillance Worksheet
NAME ADDRESS (Street and No.) PHONE Hospital Record No. ________________________ ___________________ _________________________________ __________________ ____________________ (last) (first)
This information will not be sent to CDC
REPORTING SOURCE TYPE NAME _______________________ _______________________ PH clinic ADDRESS ם physician ם ______________________ laboratory ZIP CODE ם nurse ם __ __ __ __ __ __ __ (__ __ __) other clinic PHONE ם hospital ם _______________________________________ other source type ם
LOCAL SUBJECT ID __________________________________
SUBJECT ADDRESS STATE __________________________________
SUBJECT ADDRESS COUNTY __________________________
SUBJECT ADDRESS ZIP CODE ___ ___ ___ ___ ___
CASE INFORMATION NNDSS ID ______________ (Local Record/Case ID)
Date of Birth __ __ __ __ __ __ __ __ month day year
Country of Birth ___________ Other Birthplace ______________
Ethnic Group H=Hispanic/Latino N=Not Hispanic/Latino O=Other ______________ U=Unknown Country of Usual Residence ______ Race American Indian/Alaskan Native ם Asian ם Unknown ם ________Otherם Refused to answer ם םWhite edNot askם Native Hawaiian/Pacific Islanderם Black/African American ם
Sex M=male F=female U=unknown Age at Case Investigation _____ Age Unit* ____ Date Reported __ __ __ __ __ __ __ __ month day year
Reporting State ____ Earliest Date Reported to State __ __ __ __ __ __ __ __ month day year
Date First Reported to PHD __ __ __ __ __ __ __ __ month day year
Reporting County _______ Earliest Date Reported to County __ __ __ __ __ __ __ __ month day year
National Reporting Jurisdiction _______
CDC 2019-nCOV ID _______________ Date First __ __ __ __ __ __ __ __ Positive Specimen (mm/dd/yyyy)
If probable case, reason for case classification:
Case Investigation __ __ __ __ __ __ __ __ Start Date month day year
CASE
CLASS
STATUS
Confirmed ם Unknown ם Probable ם Not a case ם Suspected ם
Meets clinical criteria AND epidemiologic evidence with no confirmatory lab testing performed for COVID-19
Meets presumptive lab evidence AND either clinical criteria OR epidemiologic evidence
Meets vital records criteria with no confirmatory lab testing
DGMQID _____________________ [If Epi-X notification of travelers checked, DGMQID]
DETECTION METHOD
Autopsy Laboratory reported Other method (specify below) Clinical evaluation Provider reported ___________________________ Contact tracing of case patient Routine physical examination ___________________________ Epi-X notification of travelers Routine surveillance Unknown
HOSPITALIZATION INFORMATION
Illness Onset Date __ __ __ __ __ __ __ __ month day year
Illness End Date __ __ __ __ __ __ __ __ month day year
Illness Duration _____ Duration Units* ______
Hospitalized? Y=yes N=no U=unknown Hospital Admission Date __ __ __ __ __ __ __ __ month day year
Hospital Discharge Date __ __ __ __ __ __ __ __ month day year
Duration of Hospital Stay 0 – 998 __________ 999=unknown (days) Patient admitted to an Intensive Care Unit (ICU)? Y=yes N=no U=unknown
If hospitalized, was a translator/Interpreter required? Y=yes N=no U=unknown ICU Admission Date __ __ __ __ __ __ __ __ month day year
If a translator was required, specify the patient's primary language: ______ ICU Discharge Date __ __ __ __ __ __ __ __ month day year
Pregnant at time of event? Y=yes N=no U=unknown If yes, trimester at illness onset: Number Weeks Gestation
Did subject die from illness/complications of illness? Y=yes N=no U=unknown Date of Death __ __ __ __ __ __ __ __ month day year *UNITS a=year d=day h=hour min=minute mo=month s=second wk=week UNK=unknown
JAN 2021 Page 1 of 5
CLINICAL INFORMATION
INFORMATION SOURCE for CLINICAL DATA
Medical records Patient interview Unknown DATE of DIAGNOSIS
__ __ __ __ __ __ __ __ month day year
Other (specify) ___________________________________________
Symptoms present during course of illness? Y=yes N=no U=unknown Did symptom(s) resolve? Y=yes N=no U=unknown
Symptom __ __ __ __ __ __ __ __ Onset Date month day year
Symptom __ __ __ __ __ __ __ __ Resolution Date month day year
Secondary Diagnosis? Y=yes N=no U=unknown (if yes, specify) __________________________________
SIGNS and SYMPTOMS
Y N U [Y=yes] Y N U [N=no] Y N U [U=unknown] Abdominal pain Subjective fever Runny nose Chest pain Fever >100.4F (38C) Sore throat Chills Headache Vomiting Cough Nausea Wheezing Diarrhea New olfactory disorder Other (specify) ____________ Difficulty breathing New taste disorder _________________________ Dyspnea Muscle aches _________________________ Fatigue Rigors Unknown
CLINICAL FINDINGS
Y N U NA [Y=yes; N=no; U=unknown] Y N U NA [NA=not applicable] Acute respiratory distress syndrome (ARDS) Other (specify) ___________________ Abnormal EKG Pneumonia Abnormal chest x-ray Unknown
TREATMENT TYPE
Y N U [Y=yes; N=no; U=unknown] DURATION (days) Y N U DURATION (days) Mechanical ventilation/intubation Other (specify) ______ ECMO Unknown
Did patient have underlying medical conditions and/or risk behaviors? Y=yes N=no U=unknown Provide response for each below: Underlying Conditions or Risk Factors [Y=yes; N=no; U=unknown] Y N U Y N U Y N U Y N U
Autoimmune condition Current smoker Hypertension Psychological/psychiatric‡
Cardiovascular disease Diabetes mellitus Immunosuppressive condition Severe obesity (BMI ≥40)
Chronic liver disease Disability† Other chronic disease Substance abuse
Chronic lung disease Former smoker Other (specify) ______________ Unknown
Chronic renal disease †If disability, type _____________________ ‡If mental condition, type ___________________
DEMOGRAPHIC INFORMATION
Tribal affiliation? Y=yes N=no U=unknown Tribal Name ___________ Enrolled Tribe Name ___________
RESIDENCE at ILLNESS
ONSET
Acute care inpatient facility Homeless shelter Long term care facility Other (specify) _________________ Apartment Hotel Mobile home Outside Assisted living facility House/single family Motel Rehabilitation facility Correctional facility Group home Nursing home Unknown
Was case-patient a healthcare personnel (HCP) at time of illness onset? Y=yes N=no U=unknown If yes, select from below:
HCP OCCUPATION
TYPE
Environmental services Nurse HCP
WORKPLACE SETTING
Assisted living facility Hospital
Respiratory therapist Physician Long term care facility Nursing home
Other Unknown Rehabilitation facility Unknown
Other (specify) ___________________________
Page 2 of 5
EXPOSURE and IMPORTATION INFORMATION In the 14 days prior to illness onset, did the patient have any of the following exposures: (check all that apply)
Y N U [Y=yes, N=no, U=unknown] Y N U Y N U Airport/Airplane Other (specify)
International travel
Adult congregate living facility Correctional facility School/university
Childcare facility Domestic travel
Community event/mass gathering Unknown exposures in the 14 days prior to illness onset
Animal (confirmed/suspected COVID-19) Animal Type ______________________________________________________________
Workplace Workplace critical infrastructure? Setting (specify) ____________________
Cruise ship or vessel travel as
Name of ship(s) 1) __________________________ 2) ___________________________
Contact with confirmed/probable COVID-19 case: community healthcare associated household other __________ unknown
If contact with COVID-19 case, was this person a U.S. case? Linked Case Number ___________________________
TRAVEL
HISTORY
International Destinations
Country Departure Date (mm/dd/yyyy) Return Date (mm/dd/yyyy) __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Domestic Destinations
State Departure Date (mm/dd/yyyy) Return Date (mm/dd/yyyy)
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
CASE DISEASE IMPORTED CODE
Indigenous In state, out of jurisdiction Out of state
International Unknown Yes, imported, but not able to determine source state/country
Imported Country ____________ Imported State _________ Imported County ______________ Imported City ___________________
Country of Exposure _______________________________________ State or Province of Exposure __________________________________ County of Exposure ________________________________________ City of Exposure ____________________________________________ Outbreak related? Y=yes N=no U=unknown Outbreak Name
Transmission Mode __ __ __ __ __ __ __ __ __
ALABORATORY INFORMATION
Test Type
Test Result
Result Units
Test Result Quantitative
Date Specimen Collected
mm dd yyyy
Specimen Type
Performing Laboratory
Specimen ID
Performing Laboratory
Type
TEST RESULT Q=Equivocal result E=Indeterminate
N=Negative NS=No significant rise in IgG
X=Not done OTH=Other (specify)
I=Pending P=Positive
S=significant rise in IgG UNK=Unknown
U=Unsatisfactory V=Vaccine type strain
W=Wild type strain
SPECIMEN TYPE 1 Bacterial isolate 9 CSF 17 NP swab 25 Saliva 33 Swab 41 Vesicle fluid 2 Blood 10 Crust 18 NP washing 26 Scab 34 Swab, skin lesion 42 Viral isolate 3 Body fluid 11 DNA 19 Nucleic acid 27 Serum 35 Swab, nasal sinus 43 Other 4 BAL 12 Dried blood 20 Oral fluid 28 Skin lesion 36 Swab, vesicular 44 Unknown 5 Buccal smear 13 Lesion 21 Oral swab 29 Specimen 37 Swab, internal nose 6 Buccal swab 14 Macular scraping 22 Plasma 30 Lung (BAL wash) 38 Throat swab 7 Capillary blood 15 Microbial isolate 23 Respiratory 31 Lavage 39 Tissue 8 Cataract 16 NP aspirate 24 RNA 32 Stool 40 Urine
PERFORMING LABORATORY TYPE
1=CDC lab 2=commercial lab 3=hospital lab 4=other 5=other clinical lab 6=public health lab 7=unknown 8=VPD testing lab
Page 3 of 5
VACCINATION HISTORY INFORMATION
Vaccinated (has the case-patient ever received a vaccine against this disease)? Y=yes N=no U=unknown
Number of doses against this disease received prior to illness onset? 0–6 99=unknown (doses)
Date of last vaccine dose against this disease prior to illness onset? __ __ __ __ __ __ __ __ (mm/dd/yyyy)
Was the case-patient vaccinated as recommended by the ACIP? Y=yes N=no U=unknown
Vaccine Type
Vaccination Date month day year
Vaccine Manuf
Vaccine Lot No.
National Drug Code
Vaccine Expiration Date
month day year
Vaccination Record
Identifier
Vaccine Event Information
Source
Vaccine Dose
Number
_______
_______
_______
_______
_______ _______
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
_____
_____
_____
_____
_____
_____
__________ __________ __________ __________ __________ __________
__________ __________ __________ __________ __________ __________
__ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __
____________
____________
___________
____________
____________
____________
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Vaccine Type
207=COVID-19, mRNA, LNP-S, PF, 100 mcg/0.5 mL dose 208=COVID-19, mRNA, LNP-S, PF, 30 mcg/0.3 mL dose 210=COVID-19, vector-nr, rS-ChAdOx1, PF, 0.5 mL dose 213=SARS-COV-2 (COVID-19) UNSPECIFIED OTH=other
Vaccine Event Information Codes 00=New immunization record 05=Other registy (historical) 08=Public agency (historical) 01=Unspecified source 06=Birth certificate (historical) OTH=Other 02=Other provider (historical) 07=School record (historical) UNK=Unknown PHC1435=Patient/parent recall (historical) PHC1436=Patient/parent written record PHC1936=Immunization Information System PP=Primary care provider 184225006=Medical record
Vaccine Manufacturer PFR=Pfizer MOD=Moderna US
Reason Not Vaccinated Per ACIP 1=religious exemption 5=MD diagnosis of previous disease 9=unknown 13=parent/patient unaware of recommendation 2=medical contraindication 6=too young 10=parent/patient forgot to vaccinate 14=missed opportunity 3=philosophical objection 7=parent/patient refusal 11=vaccine record incomplete/unavailable 15=foreign visitor 4=lab evidence of previous disease 8=other _______________ 12=parent/patient report of previous disease 16=immigrant
Vaccine History Comments
CASE NOTIFICATION
CONDITION CODE 11065 Immediate National Notifiable Condition Y=yes N=no U=unknown Date of First Verbal Notification to CDC __ __ __ __ __ __ __ __ month day year
Date of Electronic Case Notification to CDC __ __ __ __ __ __ __ __ month day year
State Case ID ______________ Legacy Case ID ________________ Date First Electonic Submission __ __ __ __ __ __ __ __ month day year
Notification Result Status Final results Correction Cannot obtain Jurisdiction Code _________________________
Binational Reporting Criteria ___ ___ ___ ___ ___ ___ ___ MMWR WEEK ___ MMWR YEAR ___ ______
Current Occupation (type of work patient does) ____________________________ Current Occupation Standardized (NIOCCS code) _________
Current Industry (type of business/industry in which patient works) _____________ Current Industry Standardized (NIOCCS code) _____________
Person Reporting to CDC ______________________ (first) NAME __________________________________ (last)
Person Reporting to CDC Email ________________ @ _________________ Person Reporting to CDC Phone Number (__ __ __) __ __ __ __ __ __ __
Comments
Page 4 of 5
https://wwwn.cdc.gov/nioccs3/https://wwwn.cdc.gov/nioccs3/
CLINICAL CASE DEFINITION§
Suspect Meets supportive laboratory evidence¶ with no prior history of being a confirmed or probable case.
Probable
Meets clinical criteria# AND epidemiologic linkage** with no confirmatory laboratory testing performed for SARS-C0V-2. Meets presumptive†† laboratory evidence. Meets vital records‡‡ criteria with no confirmatory laboratory testing performed for SARS-CoV2.
Confirmed Meets confirmatory§§ laboratory evidence.
¶Detection of specific antibody in serum, plasma, or whole blood Detection of specific antigen by immunocytochemistry in an autopsy specimen
[For suspect cases (positive serology only), jurisdictions may opt to place them in a registry for other epidemiological analyses or investigate to determine probable or confirmed status.]
_______________________________________________________________________ #In the absence of a more likely diagnosis:
• At least two of the following symptoms: fever (measured or subjective), chills, rigors, myalgia, headache, sore throat, nausea or vomiting, diarrhea, fatigue, congestion or runny nose, new olfactory disorder, new taste disorder
OR • Any one of the following symptoms: cough, shortness of breath, difficulty breathing OR • Severe respiratory illness with at least one of the following:
◦ Clinical or radiographic evidence of pneumonia, ◦ Acute respiratory distress syndrome (ARDS).
______________________________________________________________________
**One or more of the following exposures in the prior 14 days: • Close contact with a confirmed or probable case of COVID-19 disease; • Member of a risk cohort as defined by public health authorities during an outbreak. [Close contact is generally defined as being within 6 feet for at least 15 minutes. However, it depends on the exposure level and setting; for example, in the setting of an aerosol-generating procedure in healthcare settings without proper PPE, this may be defined as any duration. Data are insufficient to precisely define the duration of exposure that constitutes prolonged exposure and thus a close contact.
_____________________________________________________________
_____________________________________________________________________
______________________________________________________________________
††Detection of SARS CoV-2 by antigen test in a respiratory specimen.
‡‡A death certificate that lists COVID-19 disease or SARS-CoV-2 as an underlying cause of death or a significant condition contributing to death.
§§ Detection of SARS-CoV-2 RNA in a clinical or autopsy specimen using a molecular amplification test
§https://cdn.ymaws.com/www.cste.org/resource/resmgr/ps/positionstatement2020/Interim-20-ID-02_COVID-19.pdf
Page 5 of 5
https://cdn.ymaws.com/www.cste.org/resource/resmgr/ps/positionstatement2020/Interim-20-ID-02_COVID-19.pdf
Page of Provider Signature Date
COVID-19 Confirmed Case Investigation Worksheet
Patient Name (Last, First): CDC ID NUMBER: NBS (STATE) ID NUMBER:
Patient Date of Birth: Physical Address/Current Patient Location:
Current Sex: M F Phone:
Section of Epidemiology Infectious Disease Program | Phone 907-269-8000 | Fax 907-563-7868 | http://dhss.alaska.gov/dph/Epi/id/Pages/default.aspx Ver. 05/18/20
Epidemiologic Information
Does the patient attend day care*? Y N U If yes, specify name of facility, location, and phone number(if available): _
*Defined as a supervised group of 2 or more unrelated children for at least 4 hours per week
Does the patient reside in a congregate or long-term care facility? Y N U If yes, specify name of facility, location, and phone number(if available): _
Has the patient had recent travel history? Y N U If yes, specify location and date(s):
Has the patient had recent contact with any visitors from another village/city/state? Y N U If yes, specify location and date(s):
Is the patient a contact to a known lab-confirmed COVID-19 Case? Y N U
If yes, specify name, DOB, date(s) and nature of contact with confirmed case (if available): _
Physician: Reporting Hospital/Practice:
http://dhss.alaska.gov/dph/Epi/id/Pages/default.aspx
COVID-19 Confirmed Case Investigation Worksheet
History of Activity 2 Days Before and 7 Days After Symptom Onset Instructions: include all locations that the patient may have visited outside their home for the period of interest. This includes daily activities like shopping, sports practice, work attendance and single events such as attendance at a party, fair, festival, etc. Please also ask about visitors to their home in this time frame. Use additional pages as needed to capture this information.
Day Date Activities
INFE
CT
IOU
S P
ER
IOD
-2
-1
0 (Illness onset)
1
2
3
4
5
6
7
8
9
10
Use additional pages as needed to capture this information
Completed by: Phone: Date:
Page of Section of Epidemiology Infectious Disease Program | Phone 907-269-8000 | Fax 907-563-7868 | http://dhss.alaska.gov/dph/Epi/id/Pages/default.aspx Ver. 05/18/20
http://dhss.alaska.gov/dph/Epi/id/Pages/default.aspx
Summary of Contacts
COVID-19 Confirmed Case Investigation Worksheet
Page of
Name(s) of Investigator(s):
Name of index patient: DOB Gender
Please provide risk assessment and instructions given from each contact form. Use additional sheets as needed.
Risk assessment categories: C=Contact; GP=General Population
Instruction categories: Q=self-quarantine; OBS=self-observation
Name DOB Risk Assessment
Phone Number Type of Contact (work, household, etc.)
Instructions Date of Last Exposure
End of 14 day period(if
known)
Section of Epidemiology Infectious Disease Program | Phone 907-269-8000 | Fax 907-563-7868 | http://dhss.alaska.gov/dph/Epi/id/Pages/default.aspx Ver. 05/18/20
http://dhss.alaska.gov/dph/Epi/id/Pages/default.aspx
CONTACT of confirmed case - (SOE 2019 COVID-19 PUI form PHN 4.27.2020) Sec PRV Prim PRV
Investigator Name: Interview date:
Name of contact: DOB: Gender:
Minors: Guardian Name:___________________ ___ Guardian Job Status: Employed Unemployed Retired
Address:
Phone number(s): Email:
Name of index case: Case Infectious period start date: (2 days before symptom onset)
Date of contact’s most recent exposure to index case while index case was infectious:
Nature of contact with the index case (Describe)
Household member Yes No Intimate partner Yes No
Individual providing care in the household without using recommended infection control precautions Yes No
Individual who had close contact (< 6 feet)** for a prolonged period of time (current definition >10 minutes) Yes No
Other (e.g., someone who was coughed on by case): Yes No If yes, describe?________________________
_________________________________________________________________________________________
• Is contact with the index case ongoing (e.g. household contact or caregiver)? Yes No
• Does the contact have current/recent (past 2 weeks) history of fever or respiratory symptoms? Yes No
• If symptomatic, was the contact referred for testing? Yes No
• Does the contact have a thermometer? Yes No
• Does the contact have a mask (to be worn if symptomatic)? Yes No
Remind all contacts to call ahead to a provider and tell the provider they are a contact before seeking care.
Risk Assessment (circle one): Contact (if yes to any of the questions in the ‘Nature of Contact box’ above)
General Population-level Risk
Instructions Given* (circle one): Self-quarantine/ General guidance
*Additional information will be needed for contacts who are health care providers.
Quarantine / monitoring period ends (14 days after last contact with index case) (NOTE: those with ongoing case may need to restart
their 14 days when the case is released from isolation.)
Contact cleared date (if known):_______________________________
Checklist: • Contact emailed / faxed information sheet: Yes No
• Information submitted to relevant PHN: Yes No
• Contact entered into NBS: Yes No
** Factors to consider when defining close contact include proximity, the duration of exposure (e.g., longer exposure time likely increases exposure risk), whether the case had symptoms (e.g., coughing likely increases exposure risk) and whether the individual was wearing a facemask (which can efficiently block respiratory secretions from contaminating others and the environment).
Page of Provider Signature Section of Epidemiology Infectious Disease Program | Phone 907-269-8000 | Fax 907-563-7868 | http://dhss.alaska.gov/dph/Epi/id/Pages/default.aspx Ver. 05/18/20
CL 45 TP Code 01 02 07 30 TP Code EPSDT 547 EPI Investigation 04 Group Services 19
AT TT Medicaid # (V01.79)
Health Center HR#
POV Counsel Contact COVID-19
Other POV
Insurance Type: ☐ Medicaid ☐ Medicare ☐ Tricare ☐ Other Private Insurance ☐ Uninsured/Tribal
Race (check all that apply): ☐ American Indian/Alaska Native ☐ Asian ☐ Black/African American ☐ Hawaiian/Pacific Islander ☐ White
Number in Household ________ - Household Income (before taxes) per month _____________ - Hispanic? ☐ Yes ☐ No
http://dhss.alaska.gov/dph/Epi/id/Pages/default.aspx
COVID-19 Confirmed Case Investigation Worksheet Page of Source Investigation To be completed if suspected community transmission
Days prior to symptom onset:
DAY Instructions include all locations that the patient may have visited outside their home for the period of interest. This includes daily activities like shopping, sports practice, work
attendance and single events such as attendance at a party, fair, festival, etc. Please ask about visitors to their home. Use additional pages as necessary.
-1
-2
-3
-4
-5
-6
-7
-8
-9
-10
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-14
Completed by: Phone: _ _ Date: _ _
Section of Epidemiology Infectious Disease Program | Phone 907-269-8000 | Fax 907-563-7868 | http://dhss.alaska.gov/dph/Epi/id/Pages/default.aspx Ver. 5/18/20
http://dhss.alaska.gov/dph/Epi/id/Pages/default.aspx
pui-formCOVID-19 Confirmed Case Packet 5.5.20.pdf