0920-1011 2019 nCoV PUI Form

Internal use

CDC nCoV ID ___________

Form Approved: OMB: 0920-1011 Exp. 4/23/2020

2019 novel coronavirus (2019-nCoV) patient under investigation (PUI) form

As soon as possible, notify and send completed form to: 1) your local/state health department, and 2) CDC: email (eocreport@cdc.gov, subject line: nCoV PUI Form) or fax (770-488-7107). If you have questions, contact the CDC Emergency Operations Center (EOC) at 770-488-7100.

Today’s date__________ State patient ID____________ NNDSS local record ID/Case ID¹ _________ State___ County________

Interviewer’s name________________________________ Phone_____________________ Email________________________

Physician’s name _________________________________ Phone_____________________ Pager or Email_________________

Sex ☐ M ☐ F Age________☐ yr ☐ mo Residency ☐ US resident ☐ Non-US resident, country_______________________

PUI Criteria

Date of symptom onset_____________________

Does the patient have the following signs and symptoms (check all that apply)?

☐ Fever² ☐ Cough ☐ Sore throat ☐ Shortness of breath

In the 14 days before symptom onset, did the patient:

Spend time in Wuhan City, China? Does the patient live in Wuhan City? ☐ Y ☐ N ☐ Unknown Date traveled to Wuhan City______ Date traveled from Wuhan City______ Date arrived in US______	☐ Y ☐ N ☐ Unknown
Have close contact3 with a person who is under investigation for 2019-nCoV while that person was ill?	☐ Y ☐ N ☐ Unknown
Have close contact3 with a laboratory-confirmed 2019-nCoV case while that case was ill?	☐ Y ☐ N ☐ Unknown

Additional Patient Information

Is the patient a health care worker? ☐ Y ☐ N ☐ Unknown

Have history of being in a healthcare facility (as a patient, worker, or visitor) in Wuhan City, China? ☐ Y ☐ N ☐ Unknown

Is patient a member of a cluster of patients with severe acute respiratory illness (e.g., fever and pneumonia requiring hospitalization) of unknown etiology in which nCoV is being evaluated? ☐ Y ☐ N ☐ Unknown

Does the patient have these additional signs and symptoms (check all that apply)?

☐ Chills ☐ Headache ☐ Muscle aches ☐ Vomiting ☐ Abdominal pain ☐ Diarrhea ☐ Other, Specify_______________

Diagnosis (select all that apply): Pneumonia (clinical or radiologic) ☐ Y ☐ N Acute respiratory distress syndrome ☐ Y ☐ N

Comorbid conditions (check all that apply): ☐ None ☐ Unknown ☐ Pregnancy ☐ Diabetes ☐ Cardiac disease ☐ Hypertension

☐ Chronic pulmonary disease ☐ Chronic kidney disease ☐ Chronic liver disease ☐ Immunocompromised ☐ Other, specify

Is/was the patient: Hospitalized? ☐ Y, admit date_____________ ☐ N Admitted to ICU? ☐ Y ☐ N

Intubated? ☐ Y ☐ N On ECMO? ☐ Y ☐ N Patient died? ☐ Y ☐ N

Does the patient have another diagnosis/etiology for their respiratory illness? ☐ Y, Specify______________ ☐ N ☐ Unknown

Respiratory diagnostic results

Test	Pos	Neg	Pending	Not done
Influenza rapid Ag ☐ A ☐ B	☐	☐	☐	☐
Influenza PCR ☐ A ☐ B	☐	☐	☐	☐
RSV	☐	☐	☐	☐
H. metapneumovirus	☐	☐	☐	☐
Parainfluenza (1-4)	☐	☐	☐	☐
Adenovirus	☐	☐	☐	☐
Rhinovirus/enterovirus	☐	☐	☐	☐
Coronavirus (OC43, 229E, HKU1, NL63)	☐	☐	☐	☐
M. pneumoniae	☐	☐	☐	☐
C. pneumoniae	☐	☐	☐	☐
Other, Specify_________	☐	☐	☐	☐

Specimens for 2019-nCoV testing

Specimen type	Specimen ID	Date collected	Sent to CDC?
NP swab			☐
OP swab			☐
Sputum			☐
BAL fluid			☐
Tracheal aspirate			☐
Stool			☐
Urine			☐
Serum			☐
Other, specify____			☐
Other, specify____			☐

¹ For NNDSS reporters, use GenV2 or NETSS patient identifier.

² Fever may not be present in some patients, such as those who are very young, elderly, immunosuppressed, or taking certain medications. Clinical judgement should be used to guide testing of patients in such situations

³ Close contact is defined as: a) being within approximately 6 feet (2 meters) or within the room or care area for a prolonged period of time (e.g., healthcare personnel, household members) while not wearing recommended personal protective equipment (i.e., gowns, gloves, respirator, eye protection); or b) having direct contact with infectious secretions (e.g., being coughed on) while not wearing recommended personal protective equipment. Data to inform the definition of close contact are limited. At this time, brief interactions, such as walking by a person, are considered low risk and do not constitute close contact.

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011).