COVID-19 Case Report Form PDF - Overview
COVID-19 Case Report Form is used to report COVID 19 Patient for laboratory confirmation.
COVID-19 is caused by a coronavirus called SARS-CoV-2. Older adults and people who have severe underlying medical conditions like heart or lung disease or diabetes seem to be at higher risk for developing more serious complications from COVID-19 illness.
COVID-19 affects different people in different ways. Infected people have had a wide range of symptoms reported – from mild symptoms to severe illness.
COVID-19 Case Report Form
Here is the format in which you Can fill the COVID-19 Case Report Form
REPORTER INFORMATION on COVID-19 Case Report Form
- Today’s Date
- Hospital/Clinic
- Clinician Name
- Phone
- Disease Reporter’s Name
- Phone
COVID-19 TESTING INFORMATION on COVID-19 Case Report Form
- Lab Name
- Specimen Collection Date
- Test type
- PCR/molecular
- Antigen requiring an instrument (Quidel Sofia, Becton-Dickinson Veritor and LumiraDx)
- Antigen without an instrument (Abbott BinaxNOW Ag card)
PATIENT INFORMATION on COVID-19 Case Report Form
- First Name
- Last Name
- Phone
- City
- Zip Code
- County
- State
- Date of Birth
- Age & Sex
- Race: White/ Black/African American/Asian/American Indian/Alaska Native /Native Hawaiian/Pacific Islander/Other
- Ethnicity
- Does the patient work in a healthcare facility or congregate setting (e.g., long-term care or assisted living facility, shelter, prison, jail)
- Facility Name
- Employee Occupation
- Does the patient live in a congregate setting? (e.g., long-term care or assisted living facility, shelter, group home, prison, jail)
- Facility Name
- Does the patient attend school or childcare?
- School/Childcare Name and City
CLINICAL INFORMATION on COVID-19 Case Report Form
- Date of symptom onset
- Asymptomatic
- Is patient hospitalized
- Pregnant
- Admit Date:
- Date of death
- Discharge Date
- Hospital Name