COVID-19 Case Report Form

Download COVID-19 Case Report Form PDF using the direct download link.

COVID-19 Case Report Form PDF

PDF NameCOVID-19 Case Report Form
Published/Updated On
Category
Primary RegionUnited States
No. of Pages1
PDF Size0.18 MB
LanguageEnglish
Source(s) / Creditswww.health.state.mn.us

Download PDF of COVID-19 Case Report Form from www.health.state.mn.us using the direct download link given at the bottom of this article.

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
Download COVID-19 Case Report Form PDF from www.health.state.mn.us using the direct download link given below.

COVID-19 Case Report Form PDF Download Link

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