Case Investigation Form

Philippine Integrated 2019 Coronavirus Disease (CoViD-19)

Disease Surveillance and (Annex C)
Response
Disease Reporting Unit/Hospital/Facility: Name of Investigator: Date of Interview:

1. Patient Profile
Last Name First Name Middle Name Birthday (mm/dd/yyyy) Age Sex: ( ) Male
( ) Female

Occupation Civil Status  Nationality Passport No.

2. Current Residence (complete/exact address)

House No./Lot/Bldg., Street, Barangay, District Municipality/City Province

Region Home Phone No. Cellphone No. Email address

Permanent/Provincial Address (complete):

3. Overseas/ Local Employment Address
Employer's Name: Occupation Place of Work:

House No./Bldg. Name Street City/Municipality Province

Country: Office Phone No.: Cellphone No.:

4. Travel History
History of travel/visit/work in other countries with a known COVID-19 ( ) Yes Port (Country ) of exit:
transmission 14 days before the onset of your signs and symptoms: ( ) No
Airline/Sea vessel: Flight/Vessel Date of Departure (mm/dd/yyyy) Date of Arrival in
Number Philippines:
5. Exposure History
History of Exposure to Known CoViD-19 Case 14 days before the onset ( ) Yes ( ) No If yes: Date of Contact with Known CoViD-19
of signs and symptoms: ( ) Unknown Case (mm/dd/yyyy):
Have you been in a place with a known ( ) Yes If yes: Place: ( ) Work place ( ) health facility
COVID-19 transmission 14 days before the ( ) No ( ) social gathering ( ) religious gathering
onset of signs and symptoms: ( ) Unknown ( ) Others: specify type:
Date when you have been in that place:
Name of the place:
List the names of persons who were with you during this (these) Name Contact number
occasion(s) and their contact numbers: 1.
Use the back part of this sheet when needed 2.
3.
6. Clinical Information
Clinical Status at Time of Report ( ) Inpatient ( ) Outpatient ( ) Discharged ( ) Died ( ) Unknown
Date of Onset of Illness (mm/dd/yyyy): Date of Admission/Consultation (mm/dd/yyyy):
Fever _________°C ( ) Cough ( ) Sore throat ( ) Colds ( ) Shortness/difficulty of breathing
Other signs/symptoms, specify Is there any history of other illness? ( ) Yes ( ) No
If YES, specify:
Chest XRAY done? ( ) Yes ( ) No Are you pregnant? ( ) Yes LMP ____________
If yes, when? ______________________ ( ) No
CXR Results: Pneumonia ( ) Yes ( ) No ( ) Pending Other Radiologic Findings:
7. Specimen Information
PCR
if YES, Date Collected Date sent to RITM Date received in RITM Virus Isolation
Specimen Collected Resu
(mm/dd/yyyy) (mm/dd/yyyy) (to be filled up by RITM) Result
lt
( ) Serum _____/_____/_____ _____/_____/____ _____/_____/_____
( ) Oropharyngeal/
_____/_____/_____ _____/_____/____ _____/_____/_____
( ) Nasopharyngeal swab
( ) Others _____/_____/_____ _____/_____/____ _____/_____/_____
No. of specimen collection RT-PCR /Swab (cumulative - including current swab):____________________
Date of Last Specimen Collection (excluding current swab date):_________________________________
Name of Specimen collector/s: ___________________________________________ Name of Specimen
Manager:______________________
8. Classification
( ) Suspect Case ( ) Probable Case ( ) Confirmed COViD-19 Case
( ) Not a Covid-19 Case, Group _____ Sub-group (specify) ____________________________________ ( ) Others __________________________
( ) Low risk ( ) Moderate risk ( ) High risk
9. Outcome
Date of Discharge (mm/dd/yyyy): Condition on Discharge:
( ) Improved ( ) Recovered ( ) Transferred ( ) Absconded ( ) Died
Name of Informant: (if patient not available) Relationship: Phone No.

Validated by (name & signature):______________________________ Remarks/Recommendations:

Date:______________________